Every finding on record at Deep Creek Health & Rehabilitation

Based on observation, interview, facility document review, and facility policy review, the facility failed to maintain an effective pest control program. Specifically, observations were made of pest activity on 2 of 2 units and in the conference room, kitchen, and communal bathroom. Findings included:A facility policy titled, “Pest Control,” revised 05/2008, revealed a section titled, “Policy Interpretation and Implementation” that specified, “This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.” The policy also indicated, “6. Maintenance services assist, when appropriate and necessary, in providing pest control services.” A Commercial Pest Control Service Agreement,” dated 10/10/2023 and signed by a facility representative on 11/07/2023, indicated, “This agreement is for an initial period of twelve months from the date of the first service and unless canceled by the purchaser, will automatically continue on a monthly basis until canceled by either party upon thirty day notice.” The document indicated the service frequency was monthly and included that the interior and exterior of the building would be serviced every three months, in January, April, July, and October. Additional interior services would be provided monthly. The document's “Terms and Conditions” indicated the services were conditioned upon payment in full of the initial charge and all regular service charges and that failure to pay such charges would result in cancelation of the plan. A document titled, “Greenbrier Regional Medical Center (GRMC) Maintenance Log” revealed observations of pest activity occurred as follows: - 12/13/2023: Southeast Unit room [ROOM NUMBER] - roaches observed in the bathroom. - 03/2024-04/2024: Southeast Unit room [ROOM NUMBER]W and room [ROOM NUMBER]W - ants observed. - 04/2024: Southeast Unit Rooms 105, 203, 209, and 213 - ants observed. - 06/2024: Southeast Unit room [ROOM NUMBER] - ants observed. - 07/2024: Southeast Unit room [ROOM NUMBER] - two separate entries indicated ants were observed and were observed all over the room. - 02/2025: Southeast Unit room [ROOM NUMBER] - ants observed. - 04/2025: Southeast Unit room [ROOM NUMBER] and room [ROOM NUMBER] – ants observed. - 06/2025: Southeast Unit room [ROOM NUMBER] and room [ROOM NUMBER] - ants observed. - 07/2025: Southeast Unit room [ROOM NUMBER] and room [ROOM NUMBER] - ants observed. Invoices dated from 11/2023 through 08/2025 indicated the facility received and was billed for pest control services for all months except January 2024, June 2024, September 2024, November 2024, and March 2025 through September 2025. 1. Observations on 09/16/2025 beginning at 9:08 AM revealed one wall-mounted fly trap with an illuminated bulb in the administrative hall near the front lobby. A second wall-mounted fly trap with an illuminated bulb was noted in the hall near the courtyard. A third wall-mounted fly trap with a bulb that was not illuminated was in the hall across from the courtyard. Each door to the courtyard was observed to have an industrial air blower mounted above the doors. During a Resident Council meeting on 09/16/2025 from 11:15 AM to 11:45 AM, six (Residents #20, # 26, 55, #61, #77, and #84) of six residents who attended the meeting reported ongoing pest activity in their rooms, described as ants, flies, gnats, and spiders. During the survey, pests were observed as follows: - 09/16/2025 at 11:15 AM: a spider was observed in the public bathroom. - 09/16/2025 at 11:25 AM: flies were observed in the dining room during a Resident Council meeting. - 09/16/2025 at 2:56 PM: flies were observed in the conference room. - 09/16/2025 at 4:30 PM: gnats were observed at the 200/300/400 hall nurses' stations. - 09/17/2025 at 1:51 PM: flies were observed at the 300/400 hall nurses' stations. - 09/18/2025 at 11:05 AM: flies were observed at the 200, 300, and 400 hall nurse's station. During an interview on 09/16/2025 at 2:51 PM, Administrator (ADM) #1 stated that the facility did not have a current pest control contract because the vendor required the facility to provide a credit card to keep on file due to a history of late payments on the account. The facility did not agree to provide a credit card, so the pest control company's services ceased after February 2025. During a phone interview on 09/16/2025 at 4:28 PM, the Executive Administrative Assistant (EAA) for the facility's prior pest control service revealed that the facility signed an initial pest control contract on 10/10/2023, and the first monthly pest service was provided on 11/10/2023. The EAA stated the facility's contract was terminated after services were provided on 02/28/2025 because of non-payment. The EAA stated the facility was notified via email of the status, and the account was then paid in full. The EAA stated that she contacted the facility to renew the contract and resume the pest control services but did not receive a return call from the facility. During an interview on 09/17/2025 at 3:33 PM, the Maintenance Director stated he was the facility contact for the pest control provider and was responsible for addressing any pest activity reported between monthly pest services. He stated that if pest activity was reported between monthly pest services, he sprayed the facility to kill the pests with products he purchased independently through a vendor available to the public. The Maintenance Director stated he was aware there was a lapse in pest services, but he was not sure why the lapse occurred. He stated the facility was in transition with different administrators, and he thought the reason for the lapse in pest services may have been a lack of payment. He further stated that the last pest control service was provided s in February 2025 and he was aware pest control services were not provided by the vendor for the last few months. The Maintenance Director stated he was aware of two resident rooms in the facility where recurrent pest activity was identified and had been difficult to manage. The Maintenance Director also stated that he had a replacement bulb for the wall mounted fly light traps, but he had not yet been able to replace the bulb. During a follow-up interview on 09/17/2025 at 3:56 PM, ADM #1 stated that if residents observed pest activity in the facility, he expected them to notify staff, so the pest activity was addressed by the Maintenance Director with appropriate pest control products. He stated that if that did not resolve the pest problem, then a pest service provider would be contacted. The ADM stated if staff witnessed pest activity, he expected staff to report to their supervisor and have it discussed in morning meeting and resolved that day by the Maintenance Director. ADM #1 stated that he expected the Maintenance Director to resolve the pest issue and to contact the pest control vendor if he could not resolve the pest issue. The Administrator said he expected pest control services to be provided to maintain an effective pest control program. During an interview on 09/17/202 at 2:53 PM, the Director of Nursing (DON) stated she expected staff to record in the maintenance logbooks at each nursing station any pest activity observed or to report pest activity directly to the Maintenance Director. The DON stated that she expected the Maintenance Director to review the maintenance logbooks daily, address any concerns, and report on the follow-up during the morning meetings. The DON stated that if the Maintenance Director could not resolve the pest activity, then he should coordinate with management and contact the pest control vendor for the pest activity to be addressed. The DON stated that she was aware of the facility's current pest activity, described as “gnats,” from discussions during the facility's morning meetings. The DON said she expected the facility to provide and maintain a pest control program that minimized pest activity. During an interview on 09/17/2025 at 3:16 PM, the former Interim Administrator (ADM #2) stated that he was the Administrator for the facility from July 2025 until Friday, 09/12/2025, and that he was aware of residents who had voiced concerns in August 2025 regarding flies in the facility. He stated the flies were coming from the door to the smoking patio. He stated that residents propped the smoking patio door open, which allowed pests to enter the facility. He stated staff were educated to monitor the door to the smoking patio to ensure the doors were closed and not held open for extended periods of time. He stated he was not aware that the pest control contract was terminated. He stated the facility received an email from the pest control provider for the account to be paid in full, and payment was made. He said after he observed pest activity in the facility in the last month, he spoke to the Maintenance Director about pest services and was told that pest services from the vendor were on hold due to lack of payment. ADM #2 stated he contacted the corporate payable clerk and verified that the facility's bill was paid, so he expected the pest control vendor to resume services, but he did not contact the pest control vendor to verify the status of current services for the facility. 2. During a tour of the kitchen on 09/17/2025 at 11:15 AM, a fly was observed flying around in the kitchen. During an interview on 09/17/2025 at 11:15 AM, the Certified Dietary Manager (CDM) stated that there were flies in the kitchen periodically. The CDM stated the occasional observations of pests in the kitchen were no comparison to the seriousness of pests observed in the rest of the building. He stated that to minimize the flies in the kitchen, staff were to ensure the double entry doors that led to the exterior of the building near the back parking area were kept closed and staff used rolled up parchment paper to swat the flies.

Based on interview and facility policy review, the facility failed to ensure an effective water management program was developed and implemented to prevent the growth of opportunistic waterborne pathogens, including Legionella, which had the potential to affect all residents residing in the facility. According to the Midnight Census report, dated 09/15/2025, the facility census was 89. Findings included:A facility policy titled, Legionella Water Management Program, revised 07/2017, revealed Our facility is committed to the prevention, detection, and control of water-borne contaminates, including Legionella. The policy also revealed a section titled, Policy Interpretation and Implementation that specified, 1. As part of the infection prevention and control program, our facility has a water management program which is overseen by the water management team. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 5. The water management program includes the following elements: a. An interdisciplinary water management team; b. A detailed description and diagram of the water system in the facility, including the following: 1) receiving; 2) cold water distribution; 3) heating; 4) hot water distribution; and 5) waste; c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: 1) Storage tanks; 2) Water heaters; 3) Filters; 4) Aerators; 5) Showerheads and hoses; 6) Misters, atomizers, air washers, and humidifiers; 7) Hot tubs; 8) Fountains; and 9) Medical devices such as CPAP machines, hydrotherapy equipment, etc. d. The identification of situations that can lead to Legionella growth, such as 1) Construction; 2) Water main breaks; 3) Changes in municipal water quality; 4) The presence of biofilm scale or sediment; 5) Water temperature fluctuations; 6) Water pressure changes; 7) Water stagnation and 8) Inadequate disinfection. G. A diagram of where control measures are applied, and j. Documentation of the program. During an interview on 09/19/2025 at 2:52 PM, the Maintenance Director stated the facility had a water management plan prior to his employment as the Maintenance Director approximately two years prior and no current testing was being performed to monitor areas for potential sources of Legionella. The Maintenance Director stated he performed checks of the water temperatures and monitored the ice machine, but he did not document that. The Maintenance Director also acknowledged he did not have a diagram or list of any areas that could be potentially at risk of being a source of waterborne bacteria and stated, This is an old building, and I don't have a clue about the plumbing. During an interview on 09/19/2025 at 4:53 PM, the Director of Nursing (DON) stated she felt that the water management plan was overseen by administration. She stated she expected the facility to develop and implement a water management plan as part of the infection control program. During an interview on 09/19/2025 at 1:57 PM, Administrator (ADM) #1 stated they no longer had a water management program after the previous administrator shut that down when the facility turned off the water fountain in the front of the building. During an interview on 09/19/2025 at 4:36 PM, the previous interim Administrator (ADM) #2 stated the facility should have an implemented water management program. He stated the facility previously had one in place until they removed all the fountains that should have extended through the entire inside and outside of the facility and included anywhere water could become stagnant in order to prevent the spread of waterborne bacteria.

Based on interview, record review, and facility policy review, the facility failed to follow up on pharmacy recommendations for 2 (Residents #66 and Resident #98) of 5 residents reviewed for unnecessary medications. Findings included:A facility policy titled Medication Regimen Reviews, revised 05/2019 revealed a section titled Interpretation and Implementation that specified, 1. The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. 8. Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the Attending Physician for each resident identified as having a non-life-threatening medication irregularity. The report contains: the residents' name, the name of the medication, the identified irregularity; and the pharmacist's recommendation. 11. If the Physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken, and he/she contacts the Medical Director (if the Medical Director is the physician of record) or the Administrator. 1. An admission Record revealed the facility admitted Resident #66 on 12/08/2022. According to the admission Record, Resident #66 had a medical history that included diagnoses of bipolar disorder and major depressive disorder. A quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/05/2025, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderately impaired cognition. Review of a Consultant Pharmacist Medication Regimen Review (MRR) Active Recommendations Lacking a Final Response document, for outcomes entered between 05/01/2025 and 05/31/2025, dated 06/02/2025 indicated, Resident #66 was receiving midodrine for orthostatic hypotension (low blood pressure when standing) every 8 hours. The document indicated, It is recommended for the first dose to be given 30-60 minutes before arising and then at 3 to 4 hourly intervals throughout the day. The document also indicated holding the dose if the resident would be lying down for any length of time was advised. Further, The last dose should NOT be taken within 4 hours before going to bed due to the potential to cause supine HYPERtension [high blood pressure]. Please consider rescheduling midodrine administration to be given at 5am, 1pm, and 5pm to minimize risk for adverse effects. No response was listed under the recommendation status. A Nursing Recommendations/Nurse Manager Report, for recommendations created between 07/01/2025 to 07/28/2025, dated 07/28/2025, indicated the following for Resident #66: - The resident was receiving levothyroxine (a thyroid medication) for hyperlipidemia (high cholesterol), as noted in the MAR (medication administration record) of the medical record. The report indicated that the facility records (physician orders sheet, MAR and/or ICD 10 code [International Classification of Diseases, 10th Revision, a globally used diagnostic coding system]) should be updated to reflect the rationale for the current use of this medication. The document revealed the Follow-Through section was blank. - Please remove pain level monitoring for aspirin order. This order is not being used for pain and therefore does not required [sic] a pain level to be recorded. Removing the requirement from the order will save on nursing time during the med-pass [medication pass]. The document revealed the Follow-Through section was blank. - The resident was receiving a routine order for midodrine for hypotension with no hold order documented. Please consider adding hold parameters to this order to evaluate if the dose is necessary. The document revealed the Follow-Through section was blank. A Note to Attending Physician/Prescriber dated 08/21/2025 revealed, Resident #66 was receiving the antipsychotic medication quetiapine 150 milligrams (mg) at night (HS) for bipolar disorder. The note indicated that an antipsychotic medication should be used only for an appropriate diagnosis as determined by Center for Medicare and Medicaid Services (CMS) regulations. Further, the document indicated Please use options below to assess: Medication is being used for (select one below): Schizophrenia, Schizoaffective disorder, Huntington's, and Tourette's. The document revealed no diagnoses had been selected by the provider. Resident #66's Order Summary Report, including all active orders dated 09/17/2025, revealed the following physician orders: - Midodrine HCl (hydrochloride) oral tablet 5mg started on 06/15/2025. Instructions directed staff to give one tablet by mouth every 8 hours related to other hypotension. No other instructions were listed. - Levothyroxine sodium oral tablet 150 mcg (micrograms) started on 02/23/2025. Instructions directed staff to give one tablet by mouth one time a day related to hyperlipidemia. - Quetiapine fumarate oral tablet 150mg started on 05/14/2025. Instructions directed staff to give one tablet by mouth at bedtime for bipolar disorder. Resident #66's Medication Administration Record (MAR) dated 09/2025 and current as of 09/17/2025 revealed an order for midodrine that was timed for administration at 0600 (6:00 AM), 1400 (2:00 PM) and 2200 (10:00 PM). No hold instructions were listed. During an interview on 09/17/2025 at 2:58 PM, the Director of Nursing (DON) stated that when she received pharmacy recommendations, she was required to delegate them on to the appropriate person for follow-up. She stated if the recommendation required a provider response, she would forward the recommendation to the physician (MD) or physician's assistant (PA) for review. The DON stated if the recommendation required a response from the nursing department, she was to forward the document to the unit manager to address. The DON reviewed the recommendations for Resident #66 and confirmed the recommendations had not yet been addressed. The DON stated although she was unaware there was a concern with pharmacy recommendation responses, she expected pharmacy recommendations to be addressed timely. During a telephone interview on 09/17/2025 at 5:01 PM, the Pharmacy Consultant (PC) stated she was assigned to the facility in July 2025. The PC stated she was aware of changes in the leadership at the facility and that the facility had fallen behind in addressing her recommendations. The PC stated if a recommendation was urgent, she would address it immediately with the facility's DON and/or the Administrator. During an interview on 09/19/2025 at 4:41 PM, the former interim Administrator (ADM) #2 stated he expected MRR recommendations to be addressed in a timely manner. 2. An admission Record revealed that Resident #98 was admitted to the facility on [DATE], with a recent readmission date of 08/26/2025. According to the admission Record, the resident had a medical history with diagnoses that included a pressure ulcer of the sacral region, stage 4; paraplegia; central cord syndrome at unspecified level of cervical spinal cord; other specified depressive episodes; contractures of muscle, left lower leg; contracture of muscle, multiple sites; stiffness of the right shoulder; and stiffness of the left shoulder. A quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 08/06/2025, revealed Resident #98 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident had intact cognition. The MDS assessment also revealed the resident had physical impairments of both the upper and lower extremities bilaterally, received scheduled and as-needed pain medications, and had experienced occasional pain in the previous five days described as moderate. A Care Plan Report, initiated on 04/11/2025 and revised on 04/18/2025, revealed a focus area that indicated Resident #98 had an activity daily living (ADL) self-care performance deficit related to activity intolerance, limited mobility, musculoskeletal impairment, quadriplegia, and pain in the left leg contracture and sacral area. Interventions directed staff the resident had contractures of their left lower leg that required staff to provide skin care to keep clean and to prevent skin breakdown. The Care Plan Report revised 04/18/2025, that included a focus area that indicated the resident was on pain medication therapy related to disease process for wounds, depression, and contractures. Interventions, initiated on 08/19/2025, directed staff to administer analgesic medications as ordered by the physician and monitor/document side effects and effectiveness every shift. Resident #98's Order Summary Report, dated 09/18/2025, that included active orders on 07/31/2025, contained an order started on 06/27/2025 for Voltaren External Gel 1% (Diclofenac Sodium), that included instructions to apply to bilateral shoulders/neck topically two times a day for pain – moderate arthritis. A Nursing Recommendations/Nurse Manager Report, for recommendations created between 07/01/2025 and 07/28/2025 and dated 07/28/2025, revealed that on 07/24/2025, the pharmacist completed a medication regimen review (MRR) for Resident #98. The document indicated that the order for Voltaren External Gel was missing the dose to be measured by the dosing card. The pharmacist gave examples such as lower extremity e.g. (exempli gratia, for example) knee: Topical Gel 1% (OTC or Rx): Apply 4 g [grams] to each affected area up to 4 times daily; maximum dose per joint. 16g/day, maximum total body dose (all combined joints), 32 g/day. Please provide DOSE. Resident #98's Order Summary Report, dated 09/18/2025, that included active orders on 08/31/2025, contained an order dated 08/26/2025 for Voltaren External Gel 1%, that included instructions to apply to bilateral shoulders/neck topically two times a day for pain – moderate arthritis. During an interview on 09/17/2025 at 2:58 PM, the Director of Nursing (DON) stated that when she received pharmacy recommendations, she was required to delegate them on to the appropriate person for follow-up. She stated if the recommendation required a provider response, she would forward the recommendation to the physician (MD) or physician's assistant (PA) for review. The DON stated if the recommendation required a response from the nursing department, she was to forward the document to the unit manager to address. The DON reviewed the recommendations for Resident #66 and confirmed the recommendations had not yet been addressed. The DON stated although she was unaware there was a concern with pharmacy recommendation responses, she expected pharmacy recommendations to be addressed timely. During a telephone interview on 09/17/2025 at 5:01 PM, the Pharmacy Consultant (PC) stated she was assigned to the facility in July 2025. The PC stated she was aware of changes in the leadership at the facility and that the facility had fallen behind in addressing her recommendations. The PC stated if a recommendation was urgent, she would address it immediately with the facility's DON and/or the Administrator. During a follow-up interview on 09/19/2025 at 3:40 PM, the DON stated she expected the pharmacy recommendations to be followed. She stated she was not provided with the older pharmacist's recommendations when she started four days prior and received only the previous month's recommendations. The DON indicated she would need to review Resident #98's record to determine what area needed to be treated with the medication and modify the order to reflect where to apply the medication and include instructions to follow the dosing on the box or the physician's order. During an interview on 09/19/2025 at 4:36 PM, the previous interim Administrator (ADM) #2 stated he expected the pharmacy recommendations to be reviewed with the provider and ensure they were addressed.

Based on interview, record review, facility document review, and facility policy review, the facility failed to secure smoking materials to ensure resident safety in accordance with the facility's smoking policy for 1 (Residents #59) of 3 residents sampled for smoking. The facility also failed to ensure an assessment was conducted to determine if a resident could safely smoke independently for 1 (Resident #72) of 3 residents sampled for smoking and failed to conduct smoking safety assessments quarterly for 1 (Resident #66) of 3 residents sampled for smoking. Findings included:A facility policy titled Smoking Policy-Residents, revised 01/2020, indicated This facility shall establish and maintain safe resident smoking practices. The Policy Interpretation and Implementation section specified the following:- 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker.- 7. A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff.- 11. Residents are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. 1. An admission Record revealed the facility admitted Resident #59 on 03/12/2025. According to the admission Record, the resident had a medical history that included diagnoses of multiple sclerosis and generalized muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/2025, revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. A Smoking Safety Evaluation dated 03/12/2025 indicated that Resident #59 did not utilize tobacco at the time of the resident's admission. There were no further Smoking Safety Evaluations noted in Resident #59's record. Physician Encounter notes dated from 03/17/2025 to 09/16/2025 indicated that Resident #59 was a current daily smoker. The Encounter notes indicated that smoking cessation was advised. A Progress Note dated 04/01/2025 indicated that Resident #59 was found lying in bed smoking a cigarette. The note indicated staff removed the cigarettes and lighter and educated the resident about the facility smoking policy and designated smoking area. There was no evidence to indicate the resident was found smoking in non-designated areas after this date. During an interview on 09/18/2025 at 7:20 AM, Resident #59 stated they smoked non-mentholated organic cigarettes. Resident #59 stated after dressing daily they went outside to smoke just before or after lunch and stayed outside all day. Resident #59 stated that they were not supervised while smoking and were allowed by staff to always maintain control of their smoking materials (cigarettes and lighter). Resident #59 stated they kept their cigarette and lighter in their nightstand when they were in their room and on their person when out of the room. During an interview on 09/18/2025 at 7:38 AM, Administrator (ADM) #1 stated that all smokers were able to smoke independently throughout the day except for one named resident. During an interview on 09/19/2025 at 10:10 AM, Certified Nursing Assistant (CNA) #7 stated that if a resident was an independent smoker they were allowed to smoke at any time and keep their smoking material in their possession. She stated that she was familiar with Resident #59 and was aware the resident was an independent smoker and able to maintain their own smoking materials. During an interview on 09/19/2025 at 10:14 AM, Licensed Practical Nurse (LPN) #8 stated that if a resident was assessed as an independent smoker, the resident was allowed to maintain possession of their smoking materials and was authorized to go out to the smoking patio whenever they wanted. She stated that if a resident was dependent on staff for smoking, they were monitored, and nursing would hold their smoking supplies. LPN #8 stated that Resident #59 was an independent smoker and kept their smoking supplies in their possession. During an interview on 09/18/2025 at 9:57 AM, the Physician's Assistant-Certified (PA-C) stated that Resident #59 was observed to smoke daily and this was documented in the PA-C's notes. The PA-C stated that she had counseled Resident #59 on long-term risks of smoking and had offered the resident smoking cessation program, and the resident had declined. During an interview on 09/18/2025 at 12:16 PM, the former Interim Administrator (ADM) #2 stated that he was the interim Administrator for the facility from 07/2025 until a week prior to the survey when ADM #1 started. He stated that the residents' smoking supplies were to be locked in the medication cart and residents were required to ask for them when they went to smoke. 2. An admission Record revealed the facility admitted Resident #72 on 03/05/2024. According to the admission Record, the resident had a medical history that included diagnosis of nicotine dependence. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 06/07/2025, revealed Resident #72 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #72's Care Plan Report included a focus area initiated 06/13/2025 that indicated the resident was a smoker. Interventions directed staff to instruct the resident about smoking risks and hazards and about smoking cessation aides that were available; instruct resident about the facility policy on smoking to include locations, times, and safety concerns; as well as observe clothing and skin for signs of cigarette burns. Review of the Resident #72's medical record revealed no evidence that a Smoking Safety Evaluation had been completed for the resident. During an interview on 09/19/2025 at 10:14 AM, Licensed Practical Nurse (LPN) #8 stated Resident #72 was an independent smoker and kept their smoking supplies with them. During an interview on 09/18/2025 at 12:16 PM, the former Interim Administrator (ADM) #2 stated that he was the interim Administrator for the facility from 07/2025 until a week prior to the survey when ADM #1 started. He stated that when a resident was admitted to the facility who smoked, a smoking assessment was to be completed on admission. ADM #2 also stated that the residents' smoking supplies were to be locked in the medication cart and residents would be required to ask for them when they went to smoke. During a follow-up interview on 09/19/2025 at 4:44 PM, ADM #2 stated that the previous administration eliminated or loosened some of the restrictions and monitoring of individuals who smoked to honor the rights for those residents who were more independent with smoking. He stated the reason smoking assessments were overlooked was because of repeated changes in administration, and the current administration being unaware they were not completed. He stated he expected smoking assessments to be completed on admission, quarterly, and with all changes in the residents' condition. During an interview on 09/19/2025 at 5:01 PM, the Director of Nursing (DON) stated she was unaware of concerns that the facility was not completing required smoking assessments. The DON stated she expected smoking assessments to be completed on admission, quarterly, and as needed. 3. An admission Record revealed the facility admitted Resident #66 on 12/08/2022. According to the admission Record, the resident had a medical history that included diagnoses of nicotine dependence and respiratory conditions due to smoke inhalation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 08/05/2025, revealed Resident #66 had a Brief Interview of Mental Status (BIMS) score of 9, which indicated the resident had moderately impaired cognition. Resident #66's Care Plan Report included a focus area initiated 07/26/2025 that indicated the resident used tobacco. Interventions directed staff to conduct a Smoking Safety Evaluation on admission. A Smoking Safety Evaluation dated 05/31/2024 indicated that Resident #66 could not safely light smoking materials, was not able to hold smoking material safely, was not able to extinguish materials completely in the appropriate receptacle and had been known to have cigarettes in their possession. The Smoking Safety Evaluation included recommendations that all smoking materials were to be kept at the nurses' station. A Smoking Safety Evaluation dated 08/05/2025 indicated that Resident #66 utilized tobacco and that supervision would be utilized for all residents during designated smoking times. There was no documentation of quarterly smoking safety assessments conducted between 05/31/2024 and 08/05/2025. During an interview on 09/19/2025 at 4:44 PM, Administrator (ADM) #2 stated that the previous administration eliminated or loosened some of the restrictions and monitoring of individuals who smoked to honor the rights for those residents who were more independent with smoking. He stated the reason smoking assessments were overlooked was because of repeated changes in administration, and the current administration being unaware they were not completed. He stated he expected smoking assessments to be completed on admission, quarterly, and with all changes in the residents' condition. During an interview on 09/19/2025 at 5:01 PM, the Director of Nursing (DON) stated she was unaware of concerns that the facility was not completing required smoking assessments. The DON stated she expected smoking assessments to be completed on admission, quarterly, and as needed. During the survey, no concerns were identified with unsafe handling of lit cigarettes/lighters or residents smoking outside the designated smoking area.

Based on observation, interview, record review, and facility policy review, the facility's administration failed to require adherence to the facility's smoking policy or revise the policy to appropriately direct staff on ensuring residents' smoking safety. Interviews revealed the facility's prior administration directed staff that strict adherence to the supervision and smoking material storage aspects of the policy was no longer required; however, the policy was not revised accordingly. Additionally, administration failed to identify and address inconsistencies with adherence to the policy's requirement for quarterly smoking safety assessments. The failed practice affected 3 (Residents #59, #66, and #72) of 3 residents sampled for smoking. Findings included:A facility policy titled Smoking Policy-Residents, revised 01/2020, indicated, This facility shall establish and maintain safe resident smoking practices. The Policy Interpretation and Implementation section of the policy specified the following:- 7. A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff.- 11. Residents are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. 1. An admission Record revealed the facility admitted Resident #59 on 03/12/2025. A Smoking Safety Evaluation dated 03/12/2025 indicated that Resident #59 did not utilize tobacco upon admission. There was no other Smoking Safety Evaluation noted in Resident #59's medical record. During an interview on 09/18/2025 at 7:20 AM, Resident #59 stated they began smoking after admission to the facility and were now independent with smoking and required no supervision. Resident #59 stated that they kept their cigarette and lighter in a purse their nightstand when in their room and on their person when out of the room. During an interview on 09/19/2025 at 10:10 AM, Certified Nursing Assistant (CNA) #7 stated that if a resident was an independent smoker they were allowed to keep their smoking materials in their possession. During an interview on 09/19/2025 at 10:14 AM, Licensed Practical Nurse (LPN) #8 stated that if a resident was assessed as an independent smoker, they were allowed to maintain possession of their own smoking supplies and were authorized to go out to the smoking patio whenever they wanted. LPN #8 stated that Resident #59 was an independent smoker and kept their smoking supplies on them. She stated that the former administrator modified the smoking rules to allow residents to smoke at their leisure and maintain their own smoking materials. During an interview on 09/19/2025 at 5:01 PM, the Director of Nursing (DON) stated she was unaware of concerns that the facility was not completing required smoking assessments. She stated previously, all smoking materials were kept by nursing and all smoking was supervised 2. An admission Record revealed the facility admitted Resident #66 on 12/08/2022. Resident #66's Care Plan Report included a focus area initiated on 07/26/2025 that indicated the resident used tobacco. Interventions directed staff to conduct Smoking Safety Evaluation on admission and as needed. Resident #66's medical record contained Smoking Safety Evaluations dated 05/31/2024 and 08/05/2025 that indicated the resident utilized tobacco and that supervision would be utilized for all residents during designated smoking times. There was no evidence that Smoking Safety Evaluations were completed quarterly between 05/31/2024 and 08/05/2025. During an interview on 09/19/2025 at 4:44 PM, Administrator (ADM) #2 stated that the previous administration eliminated or loosened some of the restrictions and monitoring of individuals who smoked to honor the rights for those residents who were more independent with smoking. He stated the reason smoking assessments were overlooked was because of repeated changes in administration, and the current administration being unaware they were not completed. He stated he expected smoking assessments to be completed on admission, quarterly, and with all changes in the residents' condition. During an interview on 09/19/2025 at 5:01 PM, the Director of Nursing (DON) stated she was unaware of concerns that the facility was not completing required smoking assessments. The DON stated she expected smoking assessments to be completed on admission, quarterly, and as needed. 3. An admission Record revealed the facility admitted Resident #72 on 03/05/2024. Resident #72's medical record contained no evidence that a smoking safety assessment had been conducted. During an interview on 09/19/2025 at 10:14 AM, Licensed Practical Nurse (LPN) #8 stated Resident #72 was an independent smoker and kept their smoking supplies with them. During an interview on 09/19/2025 at 4:44 PM, the former Administrator (ADM) #2 stated with the repeated changes in administration, smoking assessments were overlooked, and the facility's current administration was unaware they were not completed. He stated he expected smoking assessments to be completed on admission, quarterly, and with all changes in the residents' condition. During an interview on 09/19/2025 at 5:01 PM, Director of Nursing (DON) stated she was unaware of concerns that the facility was not completing required smoking assessments. The DON stated she expected smoking assessments to be completed on admission, quarterly, and as needed.

Based on interview, record review, facility document review, and facility policy review, the facility failed to provide residents with advanced beneficiary notices, with enough information to make informed decisions, for 2 (Resident #45 and Resident #46) of 3 residents sampled for beneficiary notices. Findings included:An undated facility policy titled Skilled Nursing Facility (SNF) Notices of Non-Coverage specified delivery requirements included, Correct form must be given and properly completed. 1. An admission Record indicated the facility admitted Resident #45 on 01/11/2025. According to the admission Record, the resident had a medical history that included diagnoses of sequelae of cerebral infraction (stroke) and chronic respiratory failure with hypoxia (failure of the lungs to adequately exchange oxygen from the air to the bloodstream). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/20/2025, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS assessment also revealed Resident #45's end date of the most recent Medicare stay was on 03/20/2025. Resident #45's Care Plan Report included a focus area initiated 07/24/2025 that indicated the resident had impaired cognition or impaired thought process due to dementia. Interventions directed staff to communicate with the resident/family/caregivers regarding the resident's capabilities and needs. The Care Plan Report also included a focus area initiated on 01/19/2025 that indicated the resident had a communication problem related to aphasia, difficulty understanding others, and difficulty making decisions, making self-understood and had slurred speech. Interventions directed staff to monitor and document the resident's ability to express and comprehend language, memory reasoning ability, and problem-solving ability. A SNF Beneficiary Notification Review indicated Resident #45's Medicare Part A skilled services episode started on 01/11/2025, and their last covered day of Part A services was to end on 03/20/2025. The SNF Beneficiary Notification Review indicated the facility had initiated the discharge from Medicare Part A services when benefit days were not exhausted. A Notice of Medicare Non-Coverage [NOMNC]-CMS [Centers for Medicare & Medicaid Services]-10123-NOMNC form revealed the document was signed by Resident #45 on 03/14/2025. The document did not include what Medicare Part A services were to end. A Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) CMS-10055 form revealed the document was signed by Resident #45 on 03/14/2025. The document indicated that, beginning on 03/20/2025, the resident may have to pay out of pocket for care. The form did not include the reason the care was no longer going to be provided, nor did it provide an estimate of the cost the resident may have to pay per day if they wished for services to continue. 2. An admission Record indicated the facility admitted Resident #46 on 11/01/2006 with a recent readmission on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of metabolic encephalopathy (condition when the brain does not receive adequate oxygen or nutrients) and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body that affects the arm, leg or face) following cerebral infraction (stroke) affecting right dominant side. A five-day Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/02/2025, revealed Resident #46 had a Brief Interview of Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS assessment did not include an end date of the most recent Medicare stay. Resident #46's Care Plan Report included a focus area initiated 09/15/2024 that indicated the resident had a communication problem related to unclear speech, difficulty understanding others, and difficulty making their needs known. Interventions directed staff to ask yes/no questions if appropriate, use simple, brief, consistent words, and use alternate communication tools as needed. A SNF Beneficiary Notification Review indicated Resident #46's Medicare Part A skilled services episode started on 06/30/2025, and their last covered day of Part A services was to end on 07/30/2025. The SNF Beneficiary Notification Review indicated the facility had initiated the discharge from Medicare Part A when benefit days were not exhausted. The document also revealed a Skilled Nursing Facility [SNF] Advance Beneficiary Notice [ABN] of Non-Coverage (SNF-ABN Form CMS [Centers for Medicare & Medicaid Services] 10055) had not been provided to the resident. A Notice of Medicare Non-Coverage-CMS-10095 form indicated a verbal authorization was obtained from Resident #46 and the document was signed by staff on behalf of the resident on 07/28/2025. The document indicated the residents' services were to end on 07/30/2025 but did not indicate what Medicare Part A services were to end. During an interview on 09/16/2025 at 10:59 AM, the Business Office Manager (BOM) stated that the Social Service Director (SSD) got notification from the resident's insurance company of services ending. She stated that the BOM was responsible for maintaining a copy of the notices in a binder once the last covered day was identified, and a copy of the discharge letter was signed by the resident or their representative. During an interview on 09/17/2025 at 8:27 AM, the Social Services Director (SSD) stated that she was responsible for completing and issuing the ABN and the NOMNC notices to the resident or representatives if the resident was going home, but stated if the resident stayed in the facility, she did not provide them any forms. The SSD reviewed the NOMNC provided to Resident #45 and confirmed that the form did not contain the type of services which were to end. She stated that Resident #45 was also issued an ABN but confirmed that the reason Medicare may not pay for services and the estimated cost for the services were not included on the document. The SSD stated that therapy typically provided her with a document that indicated why the service was ending, but she did not transcribe that information on the forms that were issued to Resident #45. She stated that regarding the estimated cost, she did not have knowledge of that information and could not include it on the document. The SSD then stated that all areas of each form should be fully completed for the resident or family to make informed choices. The SSD stated that she was unsure why Resident #46's Medicare Part A services ended but thought it was ended by the resident's insurance company. The SSD reviewed the NOMNC provided to Resident #46 and acknowledged Resident #46 was not provided with the ABN document at the same time. She then stated that the NOMNC issued to Resident #46 should have included what services were to end and Resident #46 should have been provided with an ABN document. SSD then stated that all areas of each form should be fully completed for both Resident #45 and Resident #46 in order for the resident or resident's representative to make an informed choice. During an interview on 09/19/2025 at 5:01 PM, the Director of Nursing (DON) stated she was unaware there were concerns with the issuing of ABN documents. She stated her expectation was that they meet state and federal requirements, and the forms were accurate and issued timely. During an interview on 09/19/2025 at 4:44 PM, Administrator (ADM) #2 stated he was unaware there were any concerns with the issuing of ABN documents. He said he expected the ABNs to be completed, issued, and reviewed with the resident/representative at least 48 hours prior to each resident's discharge from Medicare Part A services. He stated that all appropriate areas should be completed on the form.

Based on observation, interview, record review, and facility policy review, the facility failed to provide incontinence care to 1 (Resident #12) of 3 sampled residents reviewed who were dependent on staff for assistance with activities of daily living (ADLs). Findings included:A policy titled, Activities of Daily Living (ADL), Supporting, revised 03/2018 revealed a section titled Policy Interpretation and Implementation that specified, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: c. Elimination (toileting). An admission Record indicated the facility admitted Resident #12 on 08/14/2025. The admission Record indicated diagnoses that included the need for assistance with personal care. An admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/21/2025, revealed Resident #12 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS also revealed Resident #12 had the ability to understand, to be understood, required substantial/moderate assistance of staff for toileting and personal hygiene, was not assessed to perform toilet transfers, and was always incontinent of bowel and bladder. A Care Plan Report, included a focus area revised 08/23/2025, that indicated the resident had ADL self-care performance deficits related to an unfamiliar environment, impaired mobility, and numerous medical issues. Interventions directed staff to encourage the use of the call bell to request assistance and for staff to help with ADL functions to keep the resident clean, dry, odor free, and neatly groomed. A concurrent observation and interview on 09/17/2025 at 9:40 AM revealed Resident #12 in their room seated upright in bed. A clock was observed on the wall. Resident #12 stated the resident turned their call light on around 7:00 AM that morning (09/17/2025), and when Certified Nursing Assistant (CNA) #3 responded to the call light, Resident #12 told CNA #3 that they needed incontinence care. Resident #12 stated CNA #3 told the resident that breakfast trays were about to come out, but that she would notify the assigned CNA, (CNA #6), that the resident needed incontinence care. CNA #6 then turned off the resident's call light and left the room. Resident #12 stated they received their breakfast, waited an unspecified time, then turned their call light back on. Resident #12 then said that after they put their call light back on, Licensed Practical Nurse (LPN) #5 answered the call light. The resident told LPN #5 that they needed incontinence care, and LPN #5 told the resident that the assigned CNA would be right there. Resident #12 stated that no one had changed their brief yet, and the resident had remained in a soiled brief since 7:00 AM that morning. During an interview on 09/17/2025 at 9:45 AM, CNA #6 stated she was familiar with Resident #12, and she provided nursing care to Resident #12 before. CNA #6 described Resident #12 as incontinent of bowel and bladder. CNA #6 stated she arrived at work that morning (09/17/2025) at 7:00 AM and provided Resident #12 with their breakfast tray around 7:40 AM or 7:45 AM, but that she had not been back to see the resident or provide any morning care yet. CNA #6 said she started her rounds for morning care about 45 minutes before, around 9:00 AM, and she was working her way towards Resident #12. When the surveyor shared that Resident #12 said they had been waiting for incontinence care since 7:00 AM, CNA #6 said no one told her that Resident #12 needed care, but she would continue to work her way towards Resident #12 and give the resident care as soon as she could. During an interview on 09/17/2025 at 9:50 AM, LPN #5 revealed she was about to enter a resident's room around 9:30 or 9:40 AM that morning (09/17/2025) and Resident #12's call light was illuminated. LPN #5 stated she went to Resident #12's room and asked the resident what they needed, and the resident said they needed incontinence care. LPN #5 stated that CNA #6 stuck her head out of another resident's room and said, Tell [the resident] I will be right there, so she told Resident #12 that the CNA would be right there. LPN #5 said that since CNA #6 said that she would be right there to help the resident, she did not tell CNA #6 that the resident said they needed incontinence care. During an interview on 09/17/2025 at 9:55 AM, CNA #3 said she answered the call light for Resident #12 that morning (09/17/2025) about 7:15 AM. CNA #3 said the resident said they needed incontinence care. CNA #3 said she told the resident that breakfast trays were about to come out, and she would tell CNA #6, the assigned CNA, that the resident needed incontinence care. CNA #3 further stated that there was a lot going on that morning (09/17/2025), and she forgot to tell CNA #6 that Resident #12 needed incontinence care. During a follow-up interview on 09/17/2025 at 10:30 AM, CNA #6 revealed she provided incontinence care to Resident #12 about 15 minutes prior at approximately 10:15 AM. CNA #6 clarified that she did not tell LPN #5 that she would be right there, but that she told the nurse to notify therapy staff that another resident was ready for therapy. CNA #6 said she was talking about a different resident who was waiting for her to complete morning care to attend therapy and CNA #6 stated she was not aware that Resident #12 was waiting for incontinence care. During an interview on 09/17/2025 at 10:26 AM, the Director of Nursing (DON) revealed she expected CNA #3 or LPN #5 to provide incontinence care when they answered the call light or to notify CNA #6, the assigned CNA, so that the care could be provided promptly. The DON stated residents should not be left in soiled briefs, and passing meal trays was not a reason to delay care. The DON further stated that she expected incontinence care to be provided while other staff assisted with meals. During an interview on 09/17/2025 at 4:05 PM, the Administrator (ADM) revealed he expected staff to provide the necessary care immediately. He further stated that if the assigned CNA was providing care to another resident, the staff member who answered the call light should get another CNA, or the nurse to provide incontinence care, if a CNA was unavailable.

Based on interview, record review, and facility policy review, the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASARR) was completed for 2 (Resident #66 and Resident #6) of 2 residents reviewed for PASARR. Findings included:A facility policy titled admission Criteria, dated 03/2019, indicated the Policy Interpretation and Implementation included, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for MD, ID, or RD. b. If the Level I screen indicates that the individual may meet the criteria for MD, ID, or RD, he or she is referred to the state PASARR representative for Level II (evaluation and determination) screening process. The policy also specified, 2. The social worker is responsible for making referrals to the appropriate state-designated authority. 1. An admission Record revealed the facility admitted Resident #66 on 12/08/2022. According to the admission Record, Resident #66 had a medical history that included diagnoses of bipolar disorder and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2025, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Resident #66's Care Plan Report included a focus area initiated 07/26/2025 that indicated the resident was planned for a long-term stay with no plans for discharge. Resident #66's medical record revealed no evidence of completion of a Level I or a Level II PASARR screening. During an interview on 09/16/2025 at 12:35 PM, the Administrator (ADM #1) reviewed the electronic medical record and stated there were no PASARR Level I or Level II forms available for Resident #66. The Administrator stated the resident was admitted to the facility under an exemption, as the COVID-19 public health emergency was still in effect at that time. The Administrator confirmed neither PASARR Level I nor Level II had been completed for Resident #66 since admission. The Administrator stated the social services department was responsible for the completion and submission of all PASARRs. During an interview on 09/17/2025 at 1:50 PM, the Social Services Director (SSD) stated she was responsible for completing PASARR Level II and was not familiar with who was responsible for ensuring the PASARR Level I was completed. The SSD stated she was familiar with Resident #66 and had submitted a request with the State Agency for a PASARR Level II and got a response that the resident did not meet PASARR Level II criteria. During an interview on 09/17/2025 at 2:47 PM, the SSD stated she had misspoken during her prior interview and a PASARR Level II had not been completed or submitted to the State Agency for Resident #66. The SSD stated she was not aware a PASARR Level I was not completed for Resident #66. During an interview on 09/17/2025 at 2:47 PM, the Director of Nursing (DON) stated she was not aware of who was responsible to ensure the PASARR Level I was completed upon admission. The DON stated it was her expectation that the PASARR Level I and Level II were completed timely, were accurate, and that referrals were made to the State Agency when a resident required a PASARR Level II. During an interview on 09/18/2025 at 9:01 AM, the Admissions Director (AD) stated she began employment at the facility approximately three weeks prior. She indicated each resident was required to have a PASARR Level I completed prior to admission to the facility. She stated if they did not have a PASARR Level I completed upon arrival, she would refer the admission to the DON. During an interview on 09/19/2025 at 4:41 PM with ADM #1 and the Executive Director (ADM #2), ADM #2 stated his expectation was that the PASARR process be completed timely and according to regulations. 2. An admission Record indicated the facility initially admitted Resident #6 on 07/12/2018 and readmitted the resident on 10/17/2022. According to the admission Record, the resident had a medical history that included diagnoses of unspecified mild dementia with agitation, generalized anxiety disorder, other specified depressive episodes, disorganized schizophrenia, and unspecified dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/01/2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident was taking antipsychotic and antianxiety medications. Resident #6's Care Plan Report included a focus area initiated 12/01/2024 that indicated the resident used psychotropic medications related to schizoaffective disorder, anxiety, depression, and dementia. Resident #6's medical record revealed no evidence of a Level I PASSAR screening. During an interview on 09/19/2025 at 4:25 PM, the Social Service Director (SSD) reviewed Resident #6's medical record and stated Resident #6 did not have a Level I PASSAR completed. She stated that a Level I PASSAR should have been completed at the time of the resident's admission, when there was a change in the resident's medical care, or a new diagnosis. The SSD stated she was unsure who was responsible for completing the screening for a PASARR Level I. She stated that she thought it would be the Director of Nursing (DON). During an interview on 09/19/2025 at 4:38 PM, Administrator (ADM) #2 stated that a PASSAR Level I should be completed timely and accurately.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to develop a care plan to address smoking for 1 (Resident #59) of 3 residents sampled for smoking. Findings included:The facility policy titled, Smoking Policy-Residents, revised 01/2020, indicated, This facility shall establish and maintain safe resident smoking practices. The policy also specified, 8. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan. An admission Record revealed the facility admitted Resident #59 on 03/12/2025. According to the admission Record, the resident had a medical history that included diagnoses of multiple sclerosis and generalized muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/2025, revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Physician Encounter notes dated from 03/17/2025 to 09/16/2025 indicated that Resident #59 was a current daily smoker. The Encounter notes indicated that smoking cessation was advised. Resident #59's Care Plan Report included a focus area initiated 09/18/2025 during the survey that indicated the resident used tobacco. Interventions directed staff to conduct a Smoking Safety Evaluation upon admission and as needed (PRN). There was no evidence that a care plan to address smoking was developed prior to 09/18/2025. During an interview on 09/18/2025 at 7:20 AM, Resident #59 stated they smoked non-mentholated organic cigarettes. Resident #59 stated that once they were up and dressed, they would go outside and smoke just before or after lunch and would stay outside all day, as they liked to be outside. Resident #59 stated they were not supervised and could smoke independently. Resident #59 stated they kept their cigarette and lighter in their nightstand when in their room and on their person when out of the room. Resident #59 stated that there was no instance where they had left their room without their cigarettes and lighter. During an interview on 09/18/2025 at 7:38 AM, Administrator (ADM) #1 stated that there were no designated smoking times and everyone, with the exception of one resident, was independent with smoking. During an interview on 09/19/2025 at 4:44 PM, ADM #2 stated that a care plan drew a picture of the resident. He stated that his expectation was that for residents who were assessed as individuals who smoked, this information should be reflected in their care plans and appropriate interventions should be in place. During an interview on 09/19/2025 at 5:01 PM, the Director of Nursing (DON) stated that everyone should have a care plan in place to address each person's individual concerns. She stated that Resident #59 should be offered a cessation program, and there was a due process. She stated that her expectation was that there was a care plan in place related to smoking when it had been identified that a resident smoked.

Based on a family interview, staff interviews, clinical record review, and review of documents, the facility's staff failed to adequately position Resident #1 on an unfamiliar piece of equipment, an egg crate mattress used as a transfer/slide device for obese residents. The facility staff also failed to provide supervision by leaving the resident's room and not leaving the bed in the lowest position. Resident #1, one (1) of Seven (7) residents in the survey sample, fell from the bed and sustained injuries. The findings included: Resident #1 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. She was discharged from the facility on the same day back to an acute care hospital. The current diagnoses included end-stage renal disease with dependence on hemodialysis and morbid obesity. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/16/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring an 8. This indicated Resident #1 cognitive abilities for daily decision-making were moderately impaired. In section G(Physical functioning) the resident was coded as requiring total care of one person with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing, and supervision after set-up. Resident #1's person-centered care plan revised on 2/16/2023 identified the resident as having end stage renal disease. The goal for the resident was that she would have no complications related to hemodialysis (resident received Dialysis on Tuesdays, Thursdays, and Saturdays from 9:45 a.m. to 1:30 p.m.). An intervention was that the staff monitor vital signs as ordered and notify the physician of abnormal findings. A review of the incident report dated 7/31/23 at 4:35 p.m., read that Resident #1 had a fall from the bed, was observed lying face down on the floor, sustained a deep laceration to her left lower extremity, a knot with bleeding on her face above her right eye. The staff applied dressing to open areas and the resident was sent to the emergency room at 4:50 p.m. The family member was notified at 5:15 p.m. A late entry nurse's note dated 8/02/23 at 6:05 p.m., read on 7/31/23 around 4:30 p.m., Resident #1 was transferred on an air crate mattress left under her from the hospital. The resident was alert and verbal. Certified Nursing Assistants (CNAs) went into the resident's room to get her situated, but one of the CNAs noticed the resident wasn't wearing a brief, so the staff went to find briefs, and moments later a CNA yelled down the hall for help. An interview was conducted on 11/14/23 at approximately 12:30 p.m., with Certified Nursing Assistant (CNA) #2. CNA #2 said that Resident #1 was brought into her room by transport via stretcher, laying on a blow-up mattress that the hospital used, once they got her on the bed, transport left the room. CNA #2 also said that she came out of the door of the resident's room and stood in the hallway, calling down the hall for another CNA to come help her with Resident #1. CNA #2 said that she noticed as she turned around the resident had her foot hanging off the blow-up mattress and hit the floor face-first. She said the incident happened so quickly. CNA #2 said that the bed was in an up position, and the top side rails were down. CNA #2 also said that transportation usually wouldn't have that type of mattress when transferring a resident and used a flat pad for transferring which is left under a resident. CNA #2 said that she told the other CNA to get everybody and bring the crash cart after the resident fell . She stated after the nurses arrived, she left the room. An interview was conducted on 11/14/23 at approximately 12:50 p.m., with CNA #1. CNA #1 said that she noticed transport in the hallway heading to the resident's room. They had dropped the resident off and didn't let anyone know they were leaving her; normally they would have waited for a CNA to check the residents in a room. CNA #1 also said that she heard a loud sound, entered the resident's room noticed the resident was on the floor face down, and yelled for help. CNA #1 said that she was the first one on the scene and noticed that the skin on the resident's leg was split open, she had a knot on her head and noticed that she had been left on a plastic egg crate. CNA #1 said that Resident #2 responded when she asked her if she could hear her and said that her leg was hurting. On 11/14/23 at approximately 1:00 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON said transport was observed wheeling the resident towards her room, and then shortly afterward he heard someone (Licensed Practical Nurse (LPN) #1) yelling for help. The ADON said that upon entering the room, Resident #1 was observed lying face down on the floor with an open area on the skin on one of her legs with the resident saying Ouch, ooh. The ADON said the bed appeared to be extremely high and he noticed a pink, foam, plastic device used as a slide transfer for the resident. On 11/14/23 at approximately 1:15 p.m., a telephone call was made to Licensed Practical Nurse (LPN) #1 concerning the incident. LPN #1 said when Resident #1 arrived from the hospital medical transport transferred Resident #1 from their stretcher to the resident's bed with a bubble mattress left under her. The CNA was in the room at the time but went to get briefs to perform Activities of Daily Living (ADL) care. LPN #1 said that the resident shouldn't have been left alone with the bed left up. LPN #1 said that the resident was lying face down beside the bed with visible blood on the floor. She stated she observed a skin tear on her leg and a gash on her forehead. She said that Gauze was applied to the open areas until Emergency Medical Services (EMS) came. LPN #1 was asked if she was aware that Resident #1 was admitted back to the facility. She stated, Yes, but I didn't anticipate her coming back to the facility because we hadn't received a call from the hospital admissions concerning the resident's discharge. On 11/14/23 an interview was conducted with the Director of Nursing (DON), the Administrator and the Corporate Consultant Nurse (CCN) at 3:18 p.m. The DON said that if they needed to leave the room to get supplies, the bed should have been left in low position, and one staff should have stayed with the resident. The DON also said, The egg-crate device caused the fall, the hospital said they didn't send it and the transport company said they didn't have it. It wasn't documented. Normally a transport sheet from the stretcher to the bed is under the resident. The Corporate Nurse Consultant (CCN) said, They should have removed the thing (plastic egg-crate device) from under the resident. She slid on the floor because of that piece of equipment. On 11/14/23 at approximately 3:50 p.m. an interview was conducted with the transportation dispatcher, Other Staff Member (OSM) #2. OSM #2 said that when they transport residents to the facility they stop at the front desk or the nurses' station to find out which room the resident is going in. OSM #2 also said that they transfer residents to their beds and never leave the room without staff being present. A telephone interview was conducted with the Responsible Party (RP) of Resident #1 on 11/16/23 at 11:05 a.m. The RP said that Resident #1 fell out of her bed onto the floor sustaining a fracture of her left leg, left ankle, a goose egg on her forehead, and a bruise to her brain. The RP said the fall incident occurred after two CNAs came to her room to change her bed linen and briefs leaving her alone on a transfer device. The RP also said that they operated on the resident's leg but because she had weak, brittle bones from diabetes the procedure didn't go well. The RP said that the doctors wanted to amputate the resident's leg due to an infection and her hardware not working well. A telephone interview was conducted on 11/16/23 at approximately 12:10 p.m., with RN #2, a local dialysis center employee. RN #2 said that Resident #1 would come to the center with a lot of blankets, but he never saw anything underneath the resident during her transport to the center. He also said on the day she was receiving services she pulled out her needles and had to be transported to the hospital due to excessive bleeding. An interview was conducted with the non-medical transport owner, OSM #4 on 11/16/23 at approximately 1:50 p.m. OSM #4 said that they used a stretcher with a pad and hospital sheets on top to transfer residents. OSM #4 also said that they will usually see one or two vinyl egg crate devices in a month. If a patient is heavy, they transport with four people called a Lyft assist. The transport devices and sheets are left with the resident at the facility. Everything stays at the facility with the resident. OSM #4 also said that they were not the company that transported the resident on 7/31/23 because the run was canceled. An interview was conducted on 11/16/23 at approximately 2:00 p.m., concerning the plastic egg crate device left under Resident #1, with the inpatient case manager. The case manager said that the egg-crate device was a sliding mechanism used for overweight residents when a strong bed sheet does not help with transfers. In a synopsis of the event dated 7/31/23, the Director of Nursing (DON) detailed the events of Resident #1's fall that read, the resident was being transported to the facility from the hospital via transport around 4:30 p.m. and that the facility was not expecting the residents return to the facility because they hadn't received a report from the hospital. The resident was received on a plastic egg crate mattress, along with the hospital sheets under her. Once the resident was in bed, the staff stepped out of the room to get Activities of Daily Living (ADL) supplies and briefs, when they heard a loud crash and ran back into the room to find that Resident #1 had slid off the plastic egg crate and hit the floor face down, sustaining a large hematoma to the center of her forehead above the eyes and a large wound on her left leg. The Certified Nursing Assistant (CNA) immediately called for assistance and the nursing team with the DON arrived to provide first aid to the resident while waiting for 911. The X-ray report dated 7/31/23 of the resident's left knee revealed that Resident #1 X-ray results revealed a comminuted and displaced distal femur fracture of the left knee. Compression fracture in the lateral tibial plateau and proximal tibia suspected. Fibular neck fracture of indeterminate age and left chronic appearing distal tibial shaft fracture, distal fibular fracture. Distal Femur (Thighbone) Fractures of the Knee. A fracture is a broken bone. Fractures of the thighbone that occur just above the knee joint are called distal femur fractures. The distal femur is where the thighbone flares out like an upside-down Funnel. https://orthoinfo.aaos.org/en/diseases--conditions/distal-femur-thighbone-fractures-of-the-knee/ A review of hospital records read on 7/31/23 Resident #1 was transferred to the hospital at 5:14 p.m., According to the hospital records Resident #1 sustained a moderate right forehead hematoma, a mild superficial hemorrhagic contusion in the left frontal cortex, a femur fracture and Tibial Fibular fracture. A review of a trauma surgery note dated 7/31/23 at 5:31 p.m., read that the resident fell from her bed and on arrival was confused, not communicating well, and had an obvious open wound to her left lateral knee, suspicious of a fracture. A review of the hospital History and Physical (H&P) dated 7/31/23 revealed that Resident #1 was in mild distress and had a hematoma on the right forehead with an overlying bleeding abrasion. An obvious deformity of the left thigh with laceration, significant tenderness, and right elbow abrasion, able to move all extremities, eyes opened spontaneously and to command, followed some commands, and spoke incomprehensible words. The hospital admission report dated 7/31/23 read, Presented to the emergency room (ER) on 7/31/23 as trauma after a fall from her bed at the nursing home. She was found to have an open distal left femur fracture. On 8/2/23 she was taken for an Open reduction and internal fixation (ORIF) of a distal femur fracture (fx). She was recovering well for several days post-surgery. On 8/13/23 an infected hematoma of the left leg incision site, started on antibiotics with the plan to return to the OR the next day but later that day she was transferred to the Intensive Care Unit (ICU). A repeat Left Lower Leg Extremity Cat Scan (CT) revealed failure of hardware construct with proximal displacement of medial femoral condyle no longer secured with distal locking screws and much varus alignment at the fracture. At this time Orthopedic Surgery was recommended above the knee amputation and the family opted to treat with non-operative management. On 8/18/23 the family decided to forego surgery. On 8/22/23 the family opted to transition to comfort care. An interview was conducted with the Director of Nursing (DON) on 11/13/23 at approximately 3:50 p.m. concerning falls with major injuries in the facility. She said that Resident #1 had sustained a major fall with injuries on 7/31/23 after being transported back to the facility from a brief hospital stay. The DON also said that the transport company transferred the resident to the bed with everything under her. The CNAs left to get things the resident needed but left her bed high and she suffered a fall with injuries. On 11/16/23 at approximately 4:15 p.m., the above findings were shared with the Administrator, Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on staff interviews, clinical record view and facility documentation/document review the facility staff failed follow the resident's assessment and person-centered care plan related to bed mobility for one (1) out of two (2) residents (Resident #1) in the survey sample. The findings included: Resident #1 was originally admitted to the nursing facility on 10/29/21. Diagnosis for Resident #1 included but are not limited to Alzheimer's, major depressive disorder with recurrent, severe psychosis symptoms. The most recent Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 12/27/22 coded Resident #1 with a 01 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills for daily decision-making. In section G (Physical functioning) the MDS coded Resident #1 requiring total dependence of two with transfer, dressing, hygiene, bathing and toilet use, extensive assistance of two with bed mobility and supervisor with one assist with eating for Activities of Daily Living (ADL) care. Resident #1's care plan revised on 03/01/22 identified the resident required extensive assistance with grooming, toileting, bathing, dressing, and eating. The goal set for the resident by the staff the resident will maintain a clean, neat, and odor free appearance. One of the interventions/approaches the staff would use to accomplish this goal is to always use two (2) staff to aid with ADL's every shift and as needed. The care plan revised on 03/08/22 identified Resident #1 with aggressive behaviors towards staff during ADL care and extremely combative to staff. The goal set for the resident by the staff the resident will allow staff to assist her during care without being aggressive towards staff. One of the interventions/approaches the staff would use to accomplish this goal is to have a witness in room when ADL care is being provided. A review of a nurses note created by License Practical Nurse (LPN) #1 on 03/05/23 revealed Resident #1 observed with a raised area measuring 4.5 (centimeter) cm to the side of her forehead and a scratch measuring 1.5 cm x 0.5 cm, a scratch to the left cheek measuring 0.5 cm. The note further stated the area to the forehead was consistent with the resident hitting her head on the side rail and the scratches were consistent with self-infliction. The nurse attempted to trim and file the resident fingernails but was unsuccessful due to resident fighting and throwing her hands during care. An interview was conducted with Certified Nursing Assistant (CNA) #4 on 03/21/23 at approximately 4:20 p.m., who stated Resident #1 was never to be turned and repositioned with only one person. She stated the resident required at least two (2) people if not three (3) because she gets very aggressive when ADL care is provided. She stated the resident hits, spits, kicks, and bites while care is being provided. On 03/21/23 at approximately 4:25 p.m., an interview was conducted with CNA #5. She stated it takes 2 people to provide care for Resident #1. She stated the resident has physical behaviors when she is being touched. She stated Resident #1 scratches, hits, and kicks. She stated that extra person is needed to help keep the resident safe as well as the staff. An interview was conducted with the MDS Coordinator on 03/22/23 at approximately 9:40 a.m. She stated Resident #1 requires 2 people with all her ADLs except for eating. She stated two people are required due to the resident aggressive behavior when care is being provided. She stated the two (2) people were required to protect the resident from hitting the side rail; just protecting the resident from injury. On 03/22/23 at approximately 12:00 p.m., an interview was conducted with the Unit Manager. She stated Resident #1 requires two (2) assist with bed mobility, incontinent care and repositioning due to residents' aggressive behaviors towards staff when care is provided. On 03/22/23 at 1:00 p.m., the Administrator and Director of Nursing were informed of the above findings. No further information was provided prior to exit.

Based on clinical record review and staff interviews, the facility's staff failed to complete the resident required discharge Minimum Data Set (MDS) assessment within the required timeframe after each discharge from the facility. The findings included; On 7/20/21 at the end of the day meeting, a review of all offsite selected residents was conducted. CMS had identified 12 residents. Of the 12 residents six had been discharged from the facility, four had been discharged for more than 28 calendar days yet the discharge MDS assessment wasn't included in the clinical record or transmitted to CMS. CMS's Resident Assessment Instrument Version 3.0 Manual, dated October 2019, Chapter 2, page 2-37 instructions read; a discharge MDS assessment must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days) and the assessment must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days). On 7/20/21 at approximately 4:10 p.m., the Director of Nursing was asked to identify the MDS Coordinator and she stated the MDS Coordinator position was currently vacant but; they could telephone the regional MDS Coordinator for any questions. On 7/21/21 at approximately 2:00 p.m., the Clinical Specialist provided a schedule of discharge MDS assessment which hadn't been completed as required among many others. On 7/22/21 at approximately 4:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Clinical Specialist. The Clinical Specialist stated the Regional MDS Coordinator knew of the problem and was working towards addressing it. The Administrator stated a MDS Coordinator for the facility had been hired this week.

Based on review of facility documents and staff interview, the facility's staff failed to ensure a Registered Nurse was on duty for 8 consecutive hours each day The findings included: During review of staffing it was identified that a Registered Nurse (RN) had not worked at least 8 consecutive hours a day, 7 days a week over a six month timespan. The deficits were on the weekends and major holidays. An interview was conducted with the previous staffing coordinator. After a careful review of the schedules she concluded the RN coverage wasn't available 8 consecutive hours a day, 7 days a week. On 7/22/21 at approximately 4:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Clinical Specialist. The Clinical Specialist stated she wasn't aware of the RN staffing concerns. The Director of Nursing stated that was in the past but the review revealed as recent as 7/11/21 and 7/17/21, a RN didn't work 8 consecutive hours.

Based on medical record review, staff interviews and facility document review the facility failed to ensure that 10 of 56 residents in the survey sample were afforded the opportunity to formulate an Advance Directive upon admission, Residents' #52, #257, #258, #255, #26, #57, #48, #7, #25 and #94. The findings included: 1. Resident #52 was admitted to the facility initially on 8/12/20 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #52's most recent MDS (Minimum Data Set) was a Quarterly with an ARD (Assessment Reference Date) of 6/4/21. Resident #52's BIMS (Brief Interview for Mental Status) was coded as a 7 out of a possible 15 indicating the resident was moderately cognitively impaired but capable of some daily decision making. Resident #52's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Care Plan: Recommendations: Code Status-Full Code Resident #52's Comprehensive Care Plan last revised 6/29/21 was reviewed and is documented in part, as follows: Full Code Resident #52's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Start Date: 10/22/19 Order Description: Full Code Resident #52's electronic medical record was reviewed and there was no advance directive document located. On 7/21/21 at 2:15 P.M. the ASM (Administrative Staff Member) #1 was asked if he could located the advance directive for Resident #52. On 7/22/21 at 9:53 A.M. an interview was conducted with the ASM#1. The ASM#1 stated, We don't have any documentation to support that an Advance Directive was reviewed with the resident upon admission. The facility policy titled Advance Directives revised December 2006 was reviewed and is documented in part, as follows: Policy Statement: Advance Directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. On 7/22/21 at 4:25 P.M. a pre-exit debriefing was held with the ASM #1, ASM #, ASM #3 and ASM #4 were the above information was shared. Prior to exit no further information was provided. 2. Resident #257 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #257's most recent MDS (Minimum Data Set) was an Admission 5-Day with an ARD (Assessment Reference Date) of 7/6/21. Resident #257's BIMS was coded as a 12 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. Resident #257's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] History: Code Status-Full Code Resident #257's Comprehensive Care Plan last revised 7/14/21 was reviewed and is documented in part, as follows: Full Code Resident #257's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Start Date: 6/30/21 Order Description: Full Code Resident #257's electronic medical record was reviewed and there was no advance directive document located. On 7/21/21 at 2:15 P.M. the ASM#1 was asked if he could located the advance directive for Resident #257. On 7/22/21 at 9:53 A.M. an interview was conducted with the ASM#1. The ASM#1 stated, We don't have any documentation to support that an Advance Directive was reviewed with the resident upon admission. The facility policy titled Advance Directives revised December 2006 was reviewed and is documented in part, as follows: Policy Statement: Advance Directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. On 7/22/21 at 4:25 P.M. a pre-exit debriefing was held with the ASM #1, ASM #, ASM #3 and ASM #4 were the above information was shared. Prior to exit no further information was provided. 3. Resident #258 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #258's Admission 5-day MDS is in progress due to resident being a new admission. Resident #258's BIMS was coded as a 14 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. Resident #258's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] History: Code Status-Full Code Resident #258's Baseline Care Plan last revised 7/20/21 was reviewed and is documented in part, as follows: Full Code Resident #258's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Start Date: 7/12/21 Order Description: Full Code Resident #258's electronic medical record was reviewed and there was no advance directive document located. On 7/21/21 at 2:15 P.M. the ASM#1 was asked if he could located the advance directive for Resident #258. On 7/22/21 at 9:53 A.M. an interview was conducted with the ASM#1. The ASM#1 stated, We don't have any documentation to support that an Advance Directive was reviewed with the resident upon admission. The facility policy titled Advance Directives revised December 2006 was reviewed and is documented in part, as follows: Policy Statement: Advance Directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. On 7/22/21 at 4:25 P.M. a pre-exit debriefing was held with the ASM #1, ASM #, ASM #3 and ASM #4 were the above information was shared. Prior to exit no further information was provided. 4. Resident #255 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #255's Admission 5-day MDS is in progress due to resident being a new admission. Resident #255's BIMS was coded as a 5 out of a possible 15 indicating the resident was severely cognitively impaired but capable of some daily decision making. Resident #255's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] History: Code Status-Full Code Resident #255's Baseline Care Plan last revised 7/12/21 was reviewed and is documented in part, as follows: Full Code Resident #255's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Start Date: 7/9/21 Order Description: Full Code Resident #255's electronic medical record was reviewed and there was no advance directive document located. On 7/21/21 at 2:15 P.M. the ASM#1 was asked if he could located the advance directive for Resident #255. On 7/22/21 at 9:53 A.M. an interview was conducted with the ASM#1. The ASM#1 stated, We don't have any documentation to support that an Advance Directive was reviewed with the resident upon admission. The facility policy titled Advance Directives revised December 2006 was reviewed and is documented in part, as follows: Policy Statement: Advance Directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. On 7/22/21 at 4:25 P.M. a pre-exit debriefing was held with the ASM #1, ASM #, ASM #3 and ASM #4 were the above information was shared. Prior to exit no further information was provided. 5) Resident #26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26's most recent MDS (Minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/15/21. Resident #26 was coded as being severely impaired in cognitive function scoring 00 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. On 7/21/21 at 10:12 a.m., an interview was conducted with Resident #26's responsible party, her husband. Her husband had stated that upon admission, staff had only went over DNR (Do Not Resuscitate) or Full Code Status. Her husband stated that the discussion regarding additional life prolonging measures such as enteral feeding, intravenous fluids and a ventilator/tracheotomy if needed; did not occur. Review of Resident #26's clinical record revealed a Durable Do Not Resuscitate Order signed by the physician and dated for 2008 from the hospital. The following was documented: The patient is incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment because he/she is unable to understand the nature, extent, or probable consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternative to the decision .While capable of making an informed decision, the patient has executed a written advanced directive which directs that life prolonging measures be withheld or withdrawn. This document was signed by the Responsible Party. Resident #26's advanced directive could not be found in her clinical record. On 7/22/21 at 9:50 a.m., an interview was conducted with ASM (Administrative Staff Member) #1 and ASM #2, the DON (Director of Nursing). ASM #1 stated that they didn't have the advanced directive for Resident #26. ASM #1 stated that if residents have an advanced directive upon admission from the hospital, they will file that into the record. ASM #1 stated that they will offer residents to formulate an advanced directive, but if the resident refuses, they do not attempt again. ASM #1 stated that they didn't have the documentation to support that advanced directives was discussed with each resident upon admission. On 7/22/21 at approximately 4:30 p.m., ASM (Administrative Staff Member) #1, the interim Administrator; ASM #2, the DON (Director of Nursing), ASM #3, the ADON (Assistant Director of Nursing) and the Corporate Nurse #1 were made aware of the above concerns. No further information was presented prior to exit. 6) Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #57's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 4/11/21. Resident #57 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. On 7/21/21 at 2:00 p.m., an interview was conducted with Resident #57. Resident #57 could not determine if she was offered to formulate an advanced directive upon admission. Resident #57 seemed confused about what an advanced directive was. Review of Resident #57's clinical record revealed a Durable Do Not Resuscitate Order signed by the physician and resident on 7/8/20 from the hospital. The following was documented: The patient is CAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment . The next section regarding whether Resident #57 had executed an advanced directive was left blank. Resident #57's advanced directive could not be found in her clinical record or any evidence that the facility offered to assist Resident #57 with formulating an advanced directive. On 7/22/21 at 9:50 a.m., an interview was conducted with ASM (Administrative Staff Member) #1 and ASM #2, the DON (Director of Nursing). ASM #1 stated that they didn't have the advanced directive for Resident #57. ASM #1 stated that if residents have an advanced directive upon admission from the hospital, they will file that into the record. ASM #1 stated that they will offer residents to formulate an advanced directive, but if the resident refuses, they do not attempt again. ASM #1 stated that they didn't have the documentation to support that advanced directives was discussed with each resident upon admission. On 7/22/21 at approximately 4:30 p.m., ASM (Administrative Staff Member) #1, the interim Administrator; ASM #2, the DON (Director of Nursing), ASM #3, the ADON (Assistant Director of Nursing) and the Corporate Nurse #1 were made aware of the above concerns. No further information was presented prior to exit. 7) Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #48's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 4/2/21. Resident #48 was coded as being severely impaired in cognitive function scoring 00 out of 15 on the BIMS (Brief Interview for Mental Status Exam). Review of Resident #48's clinical record revealed a Durable Do Not Resuscitate Order signed by the physician and responsible party on 4/20/20 from the hospital. The following was documented: The patient is incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment because he/she is unable to understand the nature, extent, or probable consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternative to the decision .While capable of making an informed decision, the patient has executed a written advanced directive which directs that life prolonging measures be withheld or withdrawn. This document was signed by the Responsible Party .The patient has not executed a written advanced directive (living will or durable power of attorney for health care). There was no evidence that the facility offered and assisted Resident #48 with formulating an advanced directive. On 7/22/21 at 9:50 a.m., an interview was conducted with ASM (Administrative Staff Member) #1 and ASM #2, the DON (Director of Nursing). ASM #1 stated that they didn't have the advanced directive for Resident #48. ASM #1 stated that if residents have an advanced directive upon admission from the hospital, they will file that into the record. ASM #1 stated that they will offer residents to formulate an advanced directive, but if the resident refuses, they do not attempt again. ASM #1 stated that they didn't have the documentation to support that advanced directives was discussed with each resident upon admission. On 7/22/21 at approximately 4:30 p.m., ASM (Administrative Staff Member) #1, the interim Administrator; ASM #2, the DON (Director of Nursing), ASM #3, the ADON (Assistant Director of Nursing) and the Corporate Nurse #1 were made aware of the above concerns. No further information was presented prior to exit. 8. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's most recent MDS (Minimum Data Set Assessment) was a quarterly revision assessment with an ARD (assessment reference date) of 03/03/21. Resident #7 was coded as scoring 5 out of possible 15 on the BIMS (Brief Interview for Mental Status exam). This indicated Resident #7's cognitive abilities for daily decision making were severely impaired. A review of the clinical records on 7/21/21 revealed there were no advance directives in the clinical record for resident #7. 9. Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE]. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . ** Resident #32's most recent MDS (Minimum Data Set Assessment) was an annual assessment with an ARD (assessment reference date) of 03/10/21. Resident #32 was coded as scoring 10 out of possible 15 on the BIMS (Brief Interview for Mental Status exam). This indicated Resident #32's cognitive abilities for daily decision making were moderately impaired. A review of the clinical records on 7/21/21 revealed there were no advance directives in the clinical record for resident #32. 10. Resident #94 was admitted to the facility on [DATE] and readmitted on [DATE]. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #94's most recent MDS (Minimum Data Set Assessment) an annual assessment with an ARD (assessment reference date) of 05/23/21. Resident #94 was coded as scoring 3 out of possible 15 on the BIMS (Brief Interview for Mental Status exam). This indicated Resident #94's cognitive abilities for daily decision making were severely impaired. A review of Resident #94's clinical record on 7/21/21 revealed no Advanced Directive. On 07/21/21 at approximately 12:52 PM an interview was conducted with OSM #1 concerning Advance Directives on Resident #7, Resident #25 and Resident #94. She stated, No advance directives are on file. On 07/22/21 at approximately 9:45 AM an interview was conducted with the Administrator and DON (Director of Nursing) concerning Advance Directives. The Administrator stated, There is no document supporting that the Advance Directives were reviewed upon admission. On 7/22/21 at approximately 4:20 PM a Pre-exit meeting was conducted with the Administrator, Director of Nursing, The Assistant Director of Nursing and with the Corporate Clinical Nurse concerning the above issues. No supporting documents were offered.

Based on clinical record review and staff interviews, the facility's staff failed to complete a quarterly Minimum Data Set (MDS) assessment at least every 92 days for each resident. The findings included; During the course of the survey 7/20/21 through 7/22/21 many residents reviewed didn't have a current MDS assessment in the clinical record. Twenty residents were included in the survey for investigations. Eight of the twenty were missing a quarterly review and two of the twenty had missing annual MDS assessments. The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. (CMS Resident Assessment Instrument Version 3.0 Manual, dated October 2019, Chapter 2, page 2-33) On 7/20/21 at approximately 4:10 p.m., the Director of Nursing was asked to identify the MDS Coordinator and she stated the MDS Coordinator position was currently vacant but; they could telephone the regional MDS Coordinator for any questions. On 7/21/21 at approximately 2:00 p.m., the Clinical Specialist provided a schedule of late MDS assessment, a total of forty-five. On 7/22/21 at approximately 4:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Clinical Specialist. The Clinical Specialist stated the Regional MDS Coordinator knew of the problem and was working towards addressing it. The Administrator stated a MDS Coordinator for the facility had been hired this week.

Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to notify the local long term care ombudsman of an acute care transfer to the hospital for two of 56 sampled residents; Resident #48 and #52. The findings included: 1. Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #48's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 4/2/21. Resident #48 was coded as being severely impaired in cognitive function scoring 00 out of 15 on the BIMS (Brief Interview for Mental Status Exam). Review of Resident #48's clinical record revealed that she was sent out to the hospital on 1/19/21. The following nursing note was documented in part: During nursing rounds, this writer noted that resident was sweating profusely. No elevation in temp (temperature) at this time. Blood pressure was noted to be 166/144, BS (Blood Sugar) 188. Eyes fixed and dilated, non reactive to light. Resident started to display some [CONDITION(S)] like activity. Oxygen applied at 2 lpm (liters per minute) via nasal cannula .Upon reassessment, resident noted to have some facial distortion and continued convulsions. 911 called and resident transferred to (Name of hospital) for further eval. (Evaluation). Further review of Resident #48's clinical record revealed that Resident #48 had returned to the facility on [DATE]. Facility staff could not provide evidence that the local long term care (LTC) ombudsman was notified of this acute transfer to the hospital. On 7/22/21 at 11:00 a.m., an interview was conducted with OSM (Other Staff Member) #1, the social services assistant as the facility did not have a social worker. When asked the process for notifying the long term care ombudsman of facility discharges; OSM #1 stated that in her computer system she will just hit a button that says Discharges and send that generated report every month to the long term care ombudsman. OSM #1 then stated that it looked like the generated report was not capturing residents who were transferred to the hospital. OSM #1 stated that she was not aware of this until survey. When asked if she does a check system to ensure that all transfers are being reflected monthly to the LTC ombudsman, OSM #1 stated that the they were going to start doing that. OSM #1 confirmed that she could not find evidence that the LTC ombudsman was notified of Resident #48's transfer to the hospital. On 7/22/21 at approximately 4:30 p.m., ASM (Administrative Staff Member) #1, the interim Administrator; ASM #2, the DON (Director of Nursing), ASM #3, the ADON (Assistant Director of Nursing) and the Corporate Nurse #1 were made aware of the above concerns. 2. Resident #52 was admitted to the facility initially on 8/12/20 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #52's most recent MDS (Minimum Data Set) was a Quarterly with an ARD (Assessment Reference Date) of 6/4/21. Resident #52's BIMS (Brief Interview for Mental Status) was coded as a 7 out of a possible 15 indicating the resident was moderately cognitively impaired but capable of some daily decision making. Resident #52's Face Sheet was reviewed and is documented in part, as follows: Last Qualifying Hospital Stay: 06/25/2020-06/29/2020 Resident #52's Progress Notes were reviewed and are documented in part, as follows: 6/25/2020 3:22 A.M.: resident vs (vital signs) 114/66 (blood pressure), 83 (pulse), 18 (respirations), 98.2 (temperature), O2 sats (oxygen saturations) 86% percent on room air at 3 liters via n/c (nasal cannula). Nursing call placed to md(medical doctor)/awaiting return call. resident sent out via 911 to Name (hospital) for eval(evaluation) and tx (treatment). be hold and car plan sent with resident. rp (representative ) called. 6/25/20 12:58 P.M.: RP notified of resident's admittance to Name (hospital). On 7/21/21 the ASM(Administrative Staff Member) #1 was asked for documentation that the local Ombudsman was notified of Resident #55's discharge on 6/25/21. On 7/22/21 at 11:02 A.M. an interview was conducted with OSM(Other Staff Member)#1 regarding Ombudsman notification for Resident #52 hospital discharge on 6/25/21. OSM#1 stated, I wasn't here when she was discharged , I started in September. I looked through the the binder and I did not see where the Ombudsman was notified of the discharge. OSM#1 was asked when should the Ombudsman be notified. OSM #1 stated, The Ombudsman should be notified of all discharges and if there are any resident concerns. The facility policy titled Transfer or Discharge Notice last revised December 2016 was reviewed and is documented in part, as follows: Policy Interpretation and Implementation: 4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. On 7/22/21 at 4:25 P.M. a pre-exit debriefing was held with the ASM #1, ASM #, ASM #3 and ASM #4 were the above information was shared. Prior to exit no further information was provided.

Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to ensure all the required documentation including care plan goals and physician/RP (responsible party) contact information were sent with one of 56 residents; Resident #48 upon transfer to the hospital on 1/19/21. The findings included: Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #48's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 4/2/21. Resident #48 was coded as being severely impaired in cognitive function scoring 00 out of 15 on the BIMS (Brief Interview for Mental Status Exam). Review of Resident #48's clinical record revealed that she was sent out to the hospital on 1/19/21. The following nursing note was documented in part: During nursing rounds, this writer noted that resident was sweating profusely. No elevation in temp (temperature) at this time. Blood pressure was noted to be 166/144, BS (Blood Sugar) 188. Eyes fixed and dilated, non reactive to light. Resident started to display some [CONDITION(S)] like activity. Oxygen applied at 2 lpm (liters per minute) via nasal cannula .Upon reassessment, resident noted to have some facial distortion and continued convulsions. 911 called and resident transferred to (Name of hospital) for further eval. (Evaluation). There was no evidence in the clinical record or on the SBAR (Situation, background, assessment and recommendation) form dated 1/19/21 that the following documentation was sent with Resident #48 upon transfer to the hospital: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Comprehensive care plan goals On 7/21/21 at 10:04 a.m. and 12:04 p.m., an interview was attempted with Resident #48's responsible party. She could not be reached for an interview. On 7/22/21 at 1:51 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #2. Resident #48's current nurse. When asked what was sent with each resident to the hospital at the time of an acute care transfer, LPN #2 stated that the facesheet, medication list, care plan goals, and the bed hold policy would be sent with the resident. When asked if information sent would be documented, LPN #2 stated that all documents sent with the resident should be documented in a nursing note. When asked how we would know if these documents were sent if there is no evidence of a nursing note or documentation showing evidence that the above documents were sent with the resident at the time of transfer, LPN #2 stated, We wouldn't know. On 7/22/21 as of 3:00 p.m., the nurse who had sent Resident #48 out to the hospital on 1/19/21 could not be reached for an interview. On 7/22/21 at approximately 4:30 p.m., ASM (Administrative Staff Member) #1, the interim Administrator; ASM #2, the DON (Director of Nursing), ASM #3, the ADON (Assistant Director of Nursing) and the Corporate Nurse #1 were made aware of the above concerns. No further information was presented prior to exit. Facility policy titled, Transfer or Discharge notice did not address the above concerns. No further information was presented prior to exit.

Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 3 residents (Resident #34 and Resident 55) in the survey sample. The findings included: 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #34 who was discharged from skilled services with Medicare days remaining. Resident #34 was originally admitted to the nursing facility on 03/17/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34's Minimum Data Set (MDS) an OBRA quarterly assessment with an Assessment Reference Date (ARD) date of 03/22/21 coded Resident #34 a 10 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated moderate cognitive impairment. Review of the SNF Beneficiary Notification Review provided by the facility to surveyor, was noted that Resident #34 was not listed for having been issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice.). The resident had received a NOMNC (Notice of Medicare Provider Non-Coverage), however; no copy of the SNF ABN was provided. Resident #34 started a Medicare Part A stay on 03/17/21 and the last covered day of this stay was 04/02/20. Resident #34 was discharged from Medicare Part A services when benefit days were not exhausted. Resident #34 had only used 32 days of his Medicare Part A services with 68 days remaining. Resident #34 should have been issued a SNF ABN and an NOMNC. Resident #34 was only issued an NOMNC. An interview was conducted with Social Worker (SW) on 07/21/21 at approximately 11:10 a.m. When asked if Resident #34 was issued and ABN, she replied, No, I thought an ABN was only to be issued if the resident wanted to continue with skilled services and knowing that Medicaid wasn't' going to pay for the rest of their stay. 2. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #55 who was discharged from skilled services with Medicare days remaining. Resident #55 was admitted to the nursing facility on 01/08/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #55's Minimum Data Set (MDS) an OBRA Quarterly Assessment with an Assessment Reference Date (ARD) date of 04/09/21 coded Resident #55 a 09 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated moderate cognitive impairment. Review of the SNF Beneficiary Notification Review provided by the facility to surveyor, was noted that Resident #55 was not listed for having been issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice.) The resident had received a NOMNC (Notice of Medicare Provider Non-Coverage), however; no copy of the SNF ABN was provided. Resident #55 started a Medicare Part A stay on 01/08/21, and the last covered day of this stay was 02/08/21. Resident #55 was discharged from Medicare Part A services when benefit days were not exhausted. Resident #55 only used 17 days of her Medicare Part A services with 83 days remaining. Resident #55 should have been issued a SNF ABN and an NOMNC. Resident #55 was only issued an NOMNC. An interview was conducted with Social Worker (SW) on 07/21/21 at approximately 11:10 a.m. When asked if Resident #55 was issued and ABN, she replied, No, I thought an ABN was only to be issued if the resident wanted to continue with skilled services and knowing that Medicaid wasn't' going to pay for the rest of their stay. The Administrator and Director of Nursing DON) was informed during the debriefing on 07/21/21 at approximately 1:45 p.m. The facility did not present any further information about the findings. The facility did not have a policy on NOMNC, ABN or Cut Letter.

Based on information obtained during the Resident Council Meeting, and interviews, the facility staff failed to inform residents of the location of the survey book which listed the results of the most recent surveys. The findings included: A resident council meeting was held in the resident dining hall on 7/21/21 at approximately, 11:00 AM. Six residents attended the meeting. The residents stated they were not aware of the location of the survey results book or were not aware they could see the results of past surveys conducted . Upon inspection of the survey results book it was determined that the most recent complaint survey results were not posted in the survey book. The last survey posted in the survey book was dated 12/23/2019. According to the Office of Licensure and Certification complaint surveys were conducted on the following dates: 12/12/20, 2/12/21 and 4/15/21. These surveys should have been posted in the survey book for residents, family members and legal representatives to view. On 7/21/21 at approximately 11:45 AM an interview was conducted with the Activity Director (OSM/Other Staff Member #2) regarding the residents in the Resident Council staff stating they were not aware of the location of the survey book or the purpose of the survey book. The Activity Director stated, I haven't been working here that long. The above findings were shared with the Administrator, The Director of Nursing, The Assistant Director of Nursing (ADON) and the Corporate Nurse on 7/21/21 at approximately 4:40 PM during the pre-exit interview. No further comments were made.

Based on observations, clinical record review, and staff interview, the facility's staff failed to maintain a resident's dignity by ensuring the bedside drainage bag fluid was concealed from view for 1 of 56 residents (Resident #14), in the survey sample. The findings included: Resident #14 was originally admitted to the facility 12/11/18 and has never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/11/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of two people with bed mobility and transfers, total care of one person with dressing, toileting, personal hygiene and bathing, and supervision after set-up with eating. In section H (Bladder and Bowel) the resident was coded at H0100 as requiring use of an indwelling catheter. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/20/21 at approximately 1:45 p.m., Resident #14 was observed in bed with a bedside drainage bag viewable from the hallway. The drainage bag contained yellow urine. On 7/21/21 at approximately 11:00 a.m., Resident #14 was again observed in bed. Viewable from the hallway was a bedside drainage bag holding yellow urine with whitish looking particles. An interview was conducted with the Unit Manager on 7/21/21 at approximately 10:55 a.m. The Unit Manager stated the resident should have a fig leaf drainage bag (is a urinary drain bag that preserves the dignity of the patient by hiding the fluid from view with a built in Fig Leaf Cover) and it would be taken care of immediately. On 7/22/21 at approximately 4:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Clinical Specialist. The facility's Clinical Specialist the resident's drainage bag contents should not have been viewable from the hallway.

Based on observations, clinical record review and staff interviews, the facility staff failed to provide one resident (Resident #33) supervision and interventions to prevent falls in the survey sample of 33 residents. Resident # 33 had sustained multiple falls and the facility staff failed to ensure interventions were implemented including a toileting program by nursing and front wheeled walker as recommended by PT (physical therapy) on 6/13/16 and 6/21/16. On 6/22/16 Resident #33 sustained another fall, was transferred to a local hospital and diagnosed with [REDACTED]. A subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. Causes: A subdural hematoma is usually the result of a serious head injury. When it occurs this way, it is called an acute subdural hematoma. Acute subdural hematomas are among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death. (1) The findings include: 1. Resident #33 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #33 sustained a subdural hematoma with scattered areas of parenchymal hemorrhage (bleed within brain tissue) due to a fall. A Quarterly Minimum Data Set ((MDS) dated [DATE] assessed this resident in the area of Hearing/Speech/Vision as having no hearing/vision difficulties. In the area of Cognitive patterns this resident was not able to complete the Brief Interview for Mental Status (BIMS) assessment. In the area of Activities of Daily Living (ADL) this resident was assessed as requiring limited assist with bed mobility, one person physical assist with transfer, in the area of walk in room this resident was assessed as requiring one person physical assist. In the area of dressing, this resident required total assist. In the area of Bladder and Bowel this resident was assessed as always continent. In the area of falls, this resident was assessed as having one fall since re-entry. Resident #33 was observed lying across his bed on 6/21/16 at 3:03 P.M. A Fall Investigation Report dated 4/11/16 Indicated: 2:12 P.M. Alert times 2- Confused/Disoriented. Location- Resident room. Description- CNA reported resident assisted to floor after he showed he could not bear weight as he was falling he hit head on end table. Injury Type- No apparent Injury - Was a restraint in use? No. Was bed/personal alarm in use? No. were bed rails present? No. Position of bed rails? N/A. Action Taken- PT Referral. Fall Investigation - Mental Status Prior to Fall- Mental Status prior to Fall- Alert times 2. Assistive Devices by Resident - Wheelchair. Nursing note dated 4/12/16- 8:43 A.M. indicated: Reported while resident was being assisted to the bathroom, he was standing and his legs became weak, CNA assisted resident to floor, resident verbalized he did not hit his head, Neuro (neurological) checks initiated, no apparent injury noted. No new orders at this time, will follow/up with therapy for strengthening training. Nursing note dated 4/13/16- 2:30 P.M. indicated: Late entry- Resident reported to be on floor this shift, when assessed, resident noted lying on back with wheelchair on top of him, when asked what happened resident verbalized he was trying to walk, hipsters in place, no apparent injury noted. A Fall Investigation Report dated 5/16/16 indicated: 6:30 P.M. Incident witnessed- Location- Hallway. Description- Resident up walking and stumbled fell to onto buttocks with legs out in front. Injury Type- No apparent Injury. Was a restraint in use? No. Was be/personal alarm in use? No. Were bed rails present? No. Position of bed rails? N/A Fall Investigation - Location- Hallway- Position- Standing- Activity Mental status Prior to Fall- Alert. Footwear/equip at time of fall. Shoes. Assistive Devices used by Resident- Wheelchair. Resident wanting to go to bed. A 5/17/16 Physician's Progress Note indicated: Seen in room, lying in bed. Report of fall yesterday unwitnessed, no injury. Continue with fall protocol. Continue with VSS (vital signs) q (every) shift time 3 days. A Physician's Progress Note dated 5/18/16 indicated: Report by staff that patient Blood Pressure is low and he is lethargic. Seen in room lying in bed, daughter at bedside crying. Recent fall without injury. Daughter very tearful requesting patient be sent out. Will send out to ER to be evaluated and treat due to change in mental status plus hypotension. A Care Plan dated 5/16/16 indicated: Frequent falls since admission to this facility. Impulsive, poor balance and safety awareness, vision and hearing impairments. Goals - Resident will have no further falls thru next review. Approach- Call light within reach, answer promptly, No use of anticoagulant medications d/t (due to) fall history. Assistive devices as ordered. Instruct resident on appropriate use of assistive/supportive device. Analyze previous falls by resident to determine whether pattern/trend can be addressed. Frequent monitoring. Potential for fluctuating B/P (blood pressure) history of falls. Alert MD (medical doctor) to significant changes in BP. Give meds (medications) per order. A physician's orders [REDACTED]. A Physical Therapy Note dated 6/13/16 indicated: Start of Goal- 5/24/16 -The patient is able to safely transition from sit to stand requiring moderate assistance (26-75 % assist) with initiation cue and 30% verbal instruction/cues with front wheeled walker. Prior level as of 6/6/16 - The patient is able to safely transition from sit to stand requiring assistance (1-25 % assist) with front wheeled walker. End of Goal Status as of 6/13/16- The patient is able to safely transition from sit to stand requiring minimal assistance (1-25 % assist) with front wheeled walker. The 5/16/16 care plan documented the intervention of Assistive devices as ordered however review of the physician progress notes [REDACTED]. A review of the physician's order [REDACTED]. A Fall Investigation Report dated 6/17/16 indicated: At 2:10 P.M. on 6/17/16 Resident #33 attempted to walk to bathroom without assist no shoes /non skid socks. Injury type- Hematoma/Bruise Right eye. Action taken- Staff Re-education Other -Non-skid sock B/B (bowel bladder) intermitting pattern. (*Note Resident #33's care plan dated 5/16/16 did not evidence any updated interventions for ensuring proper foot wear to prevent falls). Investigation of Bruises, Skin Tears, Scratches- Type of Injury Bruising- Abrasion. Injury 1 cm area to right corner outer eye with small amount bruising outer corner of eye lid. Description of Resident at last observation prior to injury -sitting on edge bed eating lunch. Investigation of Bruise- Was hit by corner bathroom door. fell hit right corner outer eye. Nursing Note dated 6/18/16 at 8:33 A.M. indicated: Resident observed on floor by bed on his right side. Small area in center of his back has abrasion. ROM (Range of Motion) performed without c/o (complain of) pain. Stated he was going to bathroom. Resident reminded to use call light for assistance. Neuro (neurological) checks initiated from previous fall. A Fall Investigation Report dated 6/18/16 indicated: At 5:05 A.M. on 6/18/16 Resident #33 attempted to go to restroom without calling for help. Injury Type Abrasion to center of back. Mental Status- Alert- Was a restraint in use? No Was a bed/personal alarm in use? No Were bed rails present? Yes-with No crossed out indicating error. Position bed rails? Up Action taken - Other Intervention - Low bed (*Note Resident #33's care plan dated 5/16/16, failed to evidence an updated intervention for the use of a low bed). A Care Plan dated 5/16/16 for incontinence care indicated: Problem: Incontinence of B&B (bowel and bladder) at times due to Dementia, Depression. Episodes decreased with improved mobility and toileting assistance as needed. Goal: Skin will remain intact through the next review. Decrease in daily incontinent episodes by next review. Approaches: keep skin clean and dry, Medications as ordered, Treatments as ordered, Keep call light within easy reach, Notify MD of significant changes in skin, Trial of timed toileting program to improve continence, Assist with transition to toilet and clothing management PRN. Investigation of Bruises, Skin Tears, Scratches - Small abrasion with redness in center of back. Date of injury- 6/18/17. Description of Resident at time of discovery- Alert confused at times. Description of Resident at last observation prior to injury -In bed asleep. Resident on Anticoagulant- Recent fall. fell hit- back- abrasion redness. A rehabilitation Screen dated 3:00 P.M. on 6/21/16 indicated: Referral- Falls: Mobility fall risk - Concerns: Resident with reported fall past weekend self ambulating possible to bathroom. Resident unable to state unsure if resident had appropriate footwear. (*Note Resident #33 ' s care plan dated 5/16/16, did not evidence any intervention or updated interventions for ensuring proper foot wear to prevent falls) Therapy Evaluation: No Physical Therapy (PT) or Occupational Therapy (OT). Resident with no change of balance. Recently d/c (discharged ) from OT and PT with restorative nursing program. Comments: Recommend-toileting program with nursing. A Nursing Note dated 6/22/16 at 4:35 P.M. indicated: Resident noted on floor in room in front of room-mates bed at 3:15 P.M., resident noted lying on floor on R (right) - side, with twitching noted, resident lying there with blank stare, no responses to staffs attempts to communicate with resident, skin tear to (R) (right) hand noted bleeding, treatment applied. NP (Nurse Practitioner) in house notified to come and assess resident, NP gives orders to send resident out to ER VIA 911 transport. A telephone physician's orders [REDACTED].M. indicated: Send resident to ER (emergency room ) now VIA 911 for evaluation and treatment. A Hospital History and Physical dated 6/22/16 indicated: Assessment- Subdural hematoma due to fall- recurrent falls, dementia, history of aspiration, [DIAGNOSES REDACTED] and history of CAD (coronary artery disease). Plan -Stop all blood thinners including ASA (aspirin) coumadin. Spoke with daughter at length. Told her that he is not a candidate for coumadin any more due to recurrent falls. CT Impression- 1. Acute left Subdural hematoma with scattered areas of parenchymal hemorrhage involving the left cerebral hemisphere. Maximum thickness 8 mm (millimeter). No midline shift. 2. Previous infarct involving the right posterior parietal occipital lobe. History of present illness: The patient is an [AGE] year old gentleman who was unable to give any history and history is taken from EMS (emergency medical services) who stated that staff at his care facility heard him fall. They assumed that based on where he was found, he fell from a standing position. He has skin tears to the right hand. There is other obvious injury. Unable to perform adequate HPI (history present illness) and ROS (review of systems) within the constraints imposed by the patient's altered mental status. He does not follow commands. During an interview on 6/24/16 at 3:15 P.M. with the Physical Therapist Director, she stated, Resident #33 was able to ambulate with a walker. He was discharged to Restorative Nursing for transfer and mobility. During an interview on 6/24/16 at 3:33 P.M. with Licensed Practical Nurse #20 she stated, Resident #33 frequently gets up and attempts to walk alone. He will attempt to go to the bath room on his own. When asked if there were assistive devices to alert staff when he gets up, she stated, No. During an interview on 6/27/16 at 8:45 A.M. with the Director of Nursing (DON) she was asked what interventions to prevent Resident #33 had been implemented, she stated, He is very impulsive and it is difficult to re-direct him. A Fall policy indicated: The physician will assess and help identify individuals with a history of falls and risk factors for subsequent falling. The physician will identify medical conditions affecting fall risk for example, a recent stroke or medications associated with increased falling risk and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant). The Facility's policy and procedure titled Falls and Fall Risk, Managing dated 12/2007 indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. In conjunction with the Consultant Pharmacist and the nursing staff, the attending physician would identify and adjust medications that may be associated with increased risk of falling. The facility staff failed to ensure interventions were implemented to prevent further falls after Resident #33 had sustained multiple falls. The comprehensive care plan failed to evidence interventions for ensuring safe foot wear such as non - skid socks, a low bed and a toileting program with nursing to prevent falls as recommended by PT on 6/21/16. In addition the facility staff failed to provide Resident #33 with supervision and a front wheeled walker as recommended by PT on 6/13/16 to ensure safe ambulation and to prevent falls. On 6/22/16 Resident #33 had another fall was transferred to a local hospital and diagnosed with [REDACTED]. (1) This information was obtained from the website: <https://www.nlm.nih.gov/medlineplus/ency/article/ 3.htm>

Based on record review, staff, individual and family interviews, facility documentation review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide supervision and interventions to prevent injury for five residents (Resident #s 5, 21, 17, 15 and 1) of 27 Residents in the survey sample. 1. For Resident #5, the facility staff failed to provide supervision and 2 person assistance to prevent a fall while ambulating resulting in a fall with a fractured hip; 2. For Resident #21, the facility staff failed to monitor and implement behavior interventions to ensure Resident #21 was free from a resident to resident assault resulting in facial lacerations requiring sutures; 3. For Resident #17, the facility staff failed to provide an environment to ensure environmental hazards did not fall upon resident; 4. For Resident #15, the facility staff failed to implement fall prevention strategies for Resident #15 which resulted in a fall with sutures, resulting in harm; 5. For Resident #1, the facility staff failed to ensure bed equipment was secured to prevent an accident in the survey sample of 27 residents. The findings included: 1. Resident #5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 was not provided hands on supervision and 2 person assistance while ambulating with physical therapy, fell and suffered a left hip fracture. A hospital Discharge Summary dated 7/13/15 indicated: Resident #5 was admitted to the hospital after sustaining a fall. He was getting his physical therapy when he fell . He was using his walker, turned and fell to the ground, found to have a left hip fracture. An Initial Minimum Data Set ((MDS) dated [DATE] assessed this resident as having adequate hearing, able to understand and be understood. This resident was coded as a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In the area of Activities of Daily of Living (ADLs) this resident was assessed as requiring total dependence with one person physical assist with (Transfers). In the area of Functional Status this resident was coded a (2- Not stable only able to stabilize with staff assistance) for moving from seated to standing position and surface to surface transfer (transfer between bed and chair or wheelchair). A Nursing Admission assessment dated [DATE] assessed this resident in the area of Range of Motion as having weakness in left and right legs. In the area of Mobility this resident was assessed as requiring the assist of (1) for transfers and uses a wheelchair for mobility. A Nursing Admissions Assessment of Risk for Falls assessed this resident as being a High Risk for Falls. An Interim Care Plan dated 7/2/15 indicated- Problem- at risk for falls. Goal: will not sustain any injury related to falling in next 30 days. Interventions: check fall risk assessment, call bell within easy reach, cues for safety awareness, assist for toileting and transfers prn (as needed), and keep environment safe. A Facility Incident Reported dated 7/9/15 indicated: Brief Description- PTA (physical therapy assistant) ambulating with resident out rehab room. PTA following resident with w/c (wheelchair) behind him, and she was pushing feeding pump pole. (Res) resident loss balance falling to left, fell on left side (hip, elbow, shoulder, and head made contact). Report of pain. A statement of Incident dated 7/9/15 from Licence Practical Nurse (LPN) staff indicated: Responded to resident that had fallen during (PT) physical therapy/ ambulating through therapy room doorway. Upon arrival resident was noted to be laying on left side complaining of back and left shoulder pain with small amount of blood from left elbow. (VS) vital signs were obtained and (ROM) range of motion performed (WNL) within limits. order for X-ray to left shoulder, elbow and hip were ordered. Resident was returned to w/c via PTA and therapy manager and resident was returned to bed and awaited mobile X-ray to arrive. A physician's orders [REDACTED]. A nursing note dated 7/9/15 indicated: Responded to emergency to find resident on floor from a fall. C/O (complained of) pain to left shoulder, left knee, left pelvic area, denies pain to head, however, witness did see resident head hit floor. Open area to left elbow, pain to left shoulder, left elbow, left side of hip. Neuro (neurological) checks initiated. A X-ray dated 7/9/15 at 9:59 PM indicated: Impression:- There is no acute fracture or other abnormality of skull bones. Left Hip, Two Views: Findings: There is intertrochanteric fracture of the hip joint. No dislocation is seen. Radiolucent line is seen through the neck as well as trochanteric region of the femur. There are mild degenerative changes of the hip joint. There are degenerative changes of the left SI joint. Impression: There is non displaced intertrochanteric fracture of the hip joint. Clinical correlation is required, CT imaging is recommended for further evaluation. A Hospital Discharge Summary dated 7/13/15 indicated: Patient with comminuted intertrochanteric femur fracture at the request of physician for management of medical problems. Resident #5 was getting his physical therapy when he fell yesterday. He was using his walker, turned and fell to the ground, found to have a left hip fracture. He has a [DEVICE] with dressing. Assessment- left hip fracture after having a fall, did not have any premonitory symptoms of chest pain, dizziness or anything like that. Hospital Course: Pt (patient) is severely muscle wasted and appears emaciated. A Physical Therapy assessment dated [DATE] indicated: Reason for referral- Patient was referred to skilled therapy treatment secondary to acute decline in functional mobility. Pre-Cautions- falls, further decline in function, skin. Need for functional Improvement- improve overall function mobility and reduce risk of falls, tube feeding. Patient/Family stated Goals- improve walking and stop falling, get stronger. Clinical Narrative- Patient in high deconditioned state with profound generalized muscle atrophy from malnutrition, reports history of multiple falls. Patient states was modified functionally independent but was in functional decline. Patient collapsed in Food Lion unable to walk. Used assistive devices walker, cane or scooter depending on day. PT focus gait. LE (lower extremity) strengthening, balance and endurance. Miss digits 4 &5 due to amputation due to Dupentrys, contracture. PLOF (previous level of function) - Gait: PT able to walk with AD (assistive device) with modified independence. 8/10. Transfers: PT is able to to transfer with verbal/tactile cues for technique without assistance, however may have chance of LOB (loss of balance) and requires close supervision (CGA) (Contact Guard Assist) 8/10. standing Balance (+): Pt is able to reach outside BOS (balance on standing) in standing with ability to self correct LOB, however may require close supervision secondary to reach distance limitations. CLOF (current level of function)- Standing Balance Poor. During an interview on 9/22/15 at 11:10 A.M. with Resident #5, he stated, Staff was not behind him or holding onto him. He stated, I had on a gait belt. The staff was behind me pulling my wheel chair and feeding tube pump. I have a history of falling. I came here because I was falling so much at home. I fell in a supermarket parking lot and need help getting up and I said I can't keep doing this. I have no feelings in my feet. I have neuropathy. I tend to drop things. My feet are numb. You can pour hot water on them and I would never know. I have been falling a lot, my legs give out. I am losing weight. I am weak. Once I go, I am going, no walker is going to help. When I fall, I might fall to the side or backwards. But, once I start falling I go down. During an interview on 9/23/15 at 10:25 AM with the Physical Therapy Director she stated, The PTA staff was holding the tube feeding pump and pulling Resident #5 's wheel chair at the same time. Resident #5 got to the door and tried to turn and fell . He had on a gait belt but staff was not holding onto it. As soon as he hit the floor the (ADON) Assistant Director of Nursing was there. When asked how Resident #5 should have been supervised to prevent this fall, the Physical Therapy Director stated, Another staff should have assisted with the wheelchair and tube feed pole while the PTA staff held his gait belt and assisted him. He should have been a two person assist. During an interview on 9/24/15 at 11:15 AM with the Physical Therapist Assistant (PTA) she stated, I was following Resident #5 with his feeding tube pump in one and pulling his wheelchair with another. As he was walking towards the hallway from the therapy room and was turning out into the hallway he started to fall. I tried to grab him but was not able to. I should have had another staff to assist me. A Falls and Fall Risk Managing Policy dated ( Revised 8/1/2015) indicated: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation 1. Identify Interventions- The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time rather than many at once). 2. Example of Interventions- Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. If a medication is suspected as a possible cause of a resident's falling, the initial intervention might be to taper or stop that medication. 3. Adjusting Medications- In conjunction with the Consultant Pharmacist and nursing staff, the Attending Physician will identify and adjust medications that may be associated with an increased risk of falling. or indicate why those medications could not be tapered or stopped, even for a trial period. 4. Additional/Different Interventions- If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. Varying Interventions- If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. Minimizing Serious Consequences of Falls- In conjunction with the Attending Physician, staff will identify and implement relevant interventions ( e.g., hip padding or treatment of [REDACTED]. The facility staff failed to provide Resident #5 with staff supervision and 2 person assistance to prevent a fall which resulted in a left hip fracture. 2. The facility staff failed to ensure Resident #21 was free from a resident to resident altercation. Resident #21 was assaulted by Resident #25 with a metal object causing facial lacerations requiring sutures. Resident #21 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The facility staff failed to ensure (Resident #25 in the survey sample) with a known history of abusive behavior had interventions in place to prevent a resident to resident assault which resulted in injuries to Resident #21. Resident #25 assaulted Resident #21 with an air mattress pump beating him in his face and head. Resident #25's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/1/14 coded his Brief Interview of Mental Status (BIMS) as 12 out of 15 indicating moderate impairment. A 12/18/14 Minimum Data Set (MDS) assessed this resident in the area of Mood- as having no possibility of resident self harm. In the area of Behavior - Potential Indicators of Psychosis this resident was assessed as not having hallucinations or delusions. In the area of Behavioral Symptoms- Presence & Frequency this resident was assessed as having verbal behavioral symptoms directed towards others ( threatening others, screaming at others, cursing at others). In the area of Rejection of care - this resident was assessed as rejecting care daily. In the area of Psychiatric/Mood disorder this resident was not assessed in the areas of Anxiety Disorder, Manic Depression, Psychotic Disorder, Schizophrenia, and Post Traumatic Stress Disorder. Resident #25 was assessed as receiving an Antidepressant medication. A Physician' Progress Report dated: 1/20/15 indicated: Resident struck in face by roommate with metal object on 1/11/15 at approx. (1530) 3:30 PM. Staff intervened 911 notified immediately resident transported to ED (emergency room ). Contusions noted on face and lacerations to forehead and lip. CT scan of head showed no trauma or concussion. Patient returned to facility in stable condition, monitored on Q15 (every) min (minute) checks and / or 1:1. Face: Laceration 2 cm (centimeters) long above left eye brow, crusting, no active bleeding, Derma-bonded in ER. Laceration 1 cm long lateral to left eyebrow, no active bleeding also derma bonded.Contusion above left Zygomatic Process, eccymotic/swelling. laceration Left side lower lip with 2 sutures in place, no active bleeding. Neurological: Non - communicative. Shortness of breath: Controlled with Duoneb nebulizer treatments Q 4 hours. physician's orders [REDACTED]. Apply bacitracin to laceration on forehead twice daily times 7 days. may cover with dry dressing as needed for drainage. A Facility Reported Incident dated 1/11/15 indicated: Resident #21 was assaulted by his roommate Resident #25. Resident #21 received a head lacerations and facial injury. A nursing note dated 1/11/15 at 02:45 PM indicated: Resident observed agitated and cursing when I (sic) attempted to apply fentanyl Duragesic patch (narcotic pain medication). He was somewhat argumentative. he was left alone. Approximately 6 minutes later the resident was observed in the hallway. Yelling and cursing stating I tried to Kill that Mother (explicative). He was involved in an incident with another resident. he was not allowed to return to the room. He was then observed one to one by Registered Nurse (RN) supervisor. he was notably agitated. A clinical record note dated 1/8/15 at (06:00 AM) indicated: resident observed using profanity at roommate while he was lying in bed, stating he was going to hurt the roommate, roommate did not respond, this staff member asked why he was so angry, resident responded to mind my business and he (F) (Sic) me up too. I (Sic) attempted to redirect resident behavior by asking him if he was alright and if I could do anything for him, resident continued to be verbally abusive, using profanity, telling me (Sic) that when he gets up he would kill me. I (Sic) walked away to continue with medication pass, resident once up in wheelchair rammed the medication cart with wheelchair and proceeded to nursing station where he pulled things out of the box holding the vital sign machine and threw some of the equipment at the staff then left the unit, behavior to be monitored. A clinical record note dated 1/8/15 at (02:37 PM) indicated: Resident noted to have one episode of aggressive behavior. A Minimum Data Set ((MDS) dated [DATE] assessed this resident in the area of Hearing, Speech, and Vision as having adequate hearing, assessed as having Unclear speech, and assessed him as rarely/never understood and sometimes understands others. In the area of Cognitive Patterns this resident was moderately impaired and coded as decisions are poor and required supervision. Care Plan revised date (12-18-14) indicated: Problem- Self Care Deficit- requires assistance with ADLs right generalized weakness- Goal- ADL's through next review, Approaches- Staff to assist with adl PRN safety/task completion. Problem- Resident at risk for increased confusion, depression/anxiety, and self isolation due to change in environment and residents advanced dementia. Goal- Will show no increase in depression/anxiety symptoms, Approaches- Encourage out of room activities and socialization. Social Services to evaluate and visit with resident as needed. A Local Police Report dated 9/24/15 indicated: Criminal Activity Reported- Malicious Wounding. Date of Occurrence- 1/11/15. Injuries Sustained - Multiple Injuries. A Facility Report Incident Report indicated: Pt. (patient) (Resident #21) was found in bedroom in bed with acquired head injury. Received as noted -assaulted from roommate. 911 phoned for emergency services immediately. A Final Response to FRI dated 1/16/15 indicated: On 1/11/15 Resident #25 struck his roommate (Resident #21) in the head and face with an air mattress bed pump regulator that hung at the bottom of Resident #21's bed. Resident #21 sustained lacerations to his forehead. Laceration to his lower lip and two sutures were applied. Based on the the facility's investigation it was determined that this resident (Resident #21) reported to the staff when they asked him why he did it he replied because he killed his wife and daughter. This resident told the police officer that responded that this roommate was keeping him from his wife's funeral. His wife's funeral had not yet occurred as of 1/11/15. Resident #25 was discharged to a psychiatric facility. The following information is an on going timeline of Resident #25's abusive and threatening behaviors: The following noted behaviors were noted in the clinical record: An Elopement/ Wander Risk assessment dated [DATE] indicated; in the area area of mental Status this resident was assessed as being Disoriented Daily, in the area of Emotional Status this resident was assessed as being combative. A clinical note dated 10/18/14 upon admissions indicated: Daughter reports patient fractured his tibia two weeks ago and involuntarily removed his cast. When taken to hospital discovered fractured mid-femur. Daughter states after fractured tibia due to a fall was not ambulatory. A clinical note dated 10/20/14 indicated: Psychiatric: Cooperative during day, becomes agitated, verbally abusive at night. Plan: Evening episodes/verbal abuse to staff/acting out: Remeron (an antidepressant) 15 mg ( milligrams) PO (by mouth) HS (at bedtime). A clinical note dated 10/21/14- indicated: During assessment resident noted with moderate anxiety, uncooperative with repositioning and shouting out in pain prior to being touched in anticipation of being in pain on several occasions. A 10/28/14 Social Services note indicated: During this interview resident stated that he feels depressed at times, feels tired and feels that his concentration is slipping. Unit manager notified and referral made to Psychologist. A Psychological Evaluation dated 10/28/14 indicated: Resident #25 was referred for evaluation of his behavioral health status and aid with treatment planning. History- concerns about worsening behavior. Durations- weeks. Timing- at facility. Findings: Resident #25 was seen in his room and displayed depressive symptoms and behaviors. He down played depression and manifested memory loss which is suggestive of cognitive loss deficits. He has an extreme alcohol abuse/dependence history with numerous legal involvement and some treatment. Recommendations: He may benefit from Psychiatric evaluation and medication if not contraindicated. Individual counseling while at NF (nursing facility). A Psychological Test dated 10/28/14 indicated: The psychological testing was reliable and valued and the results were suggestive of depression. He is sad, unhappy, withdrawn, fearful. and isolated. A clinical note dated 11/9/14 indicated: Resident #25 refused to let CNA (certified nursing assistant) change him. A clinical note dated 11/14/14 indicated: Resident #25 found with a supply of Cymbalta. Resident stated he got his medications from home and routinely takes them. A clinical note dated 11/18/14 indicated: Resident confused, agitation noted during shift. refused all meds during medication administration. A clinical note dated 11/30/14 indicated: Resident #25 refused midnight pain medication. Resident verbally abusive to staff, and use of profanity noted. A clinical note dated 11/7/14 indicated: Resident uncooperative, refusing to let staff take vital signs, refusing medications, resident incontinent of bowel and bladder, resident with inappropriate behavior, urinating in the trash can or in cups. A clinical note dated 11/13/14 indicated: Resident uncooperative and inappropriate behavior toward staff, refuses medication on occasions, urinates in drinking cups and trash cans. A Rehab note dated 11/17/15 indicated: Resident refused this therapist twice today, exhibiting agitation and mild aggression toward therapist. Patient would not maintain own clothing management while standing, stating Pull my pants up. A Rehab note dated 11/24/14 indicated: Resident is sometimes difficult and demanding. refusing certain treatments and or declining to participate in certain tasks. I am not in the Mood. Pull my pants up. A clinical note dated 12/9/14 indicated: Resident noted to be with confusion, agitation noted during shift. Resident is encouraged to allow staff to assist during transfers and ADL's. Resident out to ortho (orthopedist) today, noted to have a lighter when he arrived back to facility. A clinical note dated 12/21/14 indicated: Resident noted with episodes of aggressive behavior toward staff when ADL (activities of daily living) rendered. A clinical record note dated 12/21/14 indicated: Resident noted to be collecting personal property from other residents, staff will continue to monitor. A clinical record note dated 12/22/14 indicated: Resident noted with aggressive behaviors towards staff with ADL care. Noncompliant behavior: Resident urinates in trash cans and in drinking cups. A clinical record note dated 12/31/14 indicated: Resident incontinent of urine, reminders to use appropriate container to urinate in appropriate place. Resident noncompliant episodes of med (medication) refusals. resident becomes agitated with staff during ADL care. A clinical record dated 1/4/15 indicated: Resident observed grabbing cna's shirt, then later apologized to cna. A clinical record note dated 1/5/15 indicated: Resident Noncompliant behavior: resident with episodes of urinating in trash cans or in drinking cups. A clinical record note dated 1/8/15 at (06:00 AM) indicated: resident observed using profanity at roommate while he was lying in bed, stating he was going to hurt the roommate, roommate did not respond, this staff member asked why he was so angry, resident responded to mind my business and he (F) (Sic) me up too. I (Sic) attempted to redirect resident behavior by asking him if he was alright and if I could do anything for him, resident continued to be verbally abusive, using profanity, telling me (Sic) that when he gets up he would kill me. I (Sic) walked away to continue with medication pass, resident once up in wheelchair rammed the medication cart with wheelchair and proceeded to nursing station where he pulled things out of the box holding the vital sign machine and threw some of the equipment at the staff then left the unit, behavior to be monitored. A clinical record note dated 1/8/15 at (02:37 PM) indicated: Resident noted to have one episode of aggressive behavior. The facilities Social Service Director was asked during an interview on 9/25/15 at 1:15 PM, why Resident #25 was not provided with on going counseling services as recommended by the Psychologist. She stated that she was not aware of the recommendation. When asked if she would be the person ensuring the services are provided she stated, Yes. During an interview on 9/24/15 at 3:15 PM with the East Unit Manager she stated, Resident #21 was just lying in bed and had not provoked Resident #25 at all. Resident #25 had a history of [REDACTED]. During an interview on 9/25/15 at 2:35 PM with the family of Resident #21 the son stated, The family had made numerous complaints to the staff concerning the abusive and threatening behavior of Resident #25. No one never did anything about it. Resident #25 would curse my family members out while visiting my father. The facility staff failed to provide staff supervision to ensure a resident (Resident #25) with a known history of of abusive and threatening behaviors did not assault Resident #21 causing injuries with harm. 3. The facility staff failed to provide Resident #17 with an environment to ensure a shower room sink did not fall on the resident. Resident #17 was re- admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/22/15 at 10:30 AM Resident #17 was heard yelling for help at the East Unit Nursing station. The sink in the shower room had fallen off the wall in the shower room striking Resident #17 across her legs. Resident #17 was observed in the East Unit Shower Room door seated in her wheelchair at 10:30 AM on 9/22/15. The resident stated to the nursing staff did you all not hear me yelling for help. The sink fell off the wall and hit me across my legs. Several nursing staff and were observed to enter the shower room. The sink was observed detached from the wall and laying on the floor. An Admission MDS dated [DATE] indicated: Resident #17 was assessed as having a BIMS score of (15) indicating no cognitive impairment. A Care Plan dated 9/15 indicated: At risk for pain due to amputee toes, PVD (peripheral vascular disease) and DM (diabetes). Goal- maintain comfort - Approaches- Document and alert MD to any significant changes related to pain. Problem- at risk for ADL deficit - Goal- will be clean, dry and well groomed, Approaches- Provide nondistracting environment for grooming. During an interview on 9/22/15 at 11:20 AM with Resident #17 she stated, I am not hurt just frightened. I never experienced anything like that in my life. The whole sink just fell off the wall. During an interview on 9/22/15 at 11:00 AM with the Maintenance Director He stated, the sink was not secure to the wall. He was asked how could a sink be not secured with faucets and pipes attached to the sink. The Maintenance Director stated, the wheel chair must have gotten underneath the sink and dislodged the sink from the wall. The facility staff failed to ensure residents environment were free of accident hazards. 4. On 9/16/15, Resident #15 was found on the floor in her room with a gash over her eye and bleeding profusely. She sustained a left sided peri-orbital injury with ecchymosis (bruising), bleeding from a laceration above the left eyebrow/forehead which required stitches. It was determined the facility staff failed to ensure interventions were in place to prevent injury from falls for Resident 15, who was identified at high risk for falling. The outcome of this incident constituted harm for Resident #15. Resident #15 was admitted to the nursing facility on 9/4/15 from hospital with [DIAGNOSES REDACTED].*intracerebral hemorrhage on 8/27/15, diabetes, high blood pressure, depression and dementia. *Intracerebral hemorrhage occurs when a diseased blood vessel within the brain bursts, allowing blood to leak inside the brain. (The name means within the cerebrum or brain). The sudden increase in pressure within the brain can cause damage to the brain cells surrounding the blood. The Minimum Data Set (MDS) assessment dated [DATE] coded the resident with short and long term memory and severely impaired in the skills needed for daily decision making. Resident #15 was coded unsteady moving from a seated position to a standing position, walking moving on and off the toilet and any surface-to-surface transfers without staff assistance. The resident was assessed to need extensive from one staff for locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. She was coded totally dependent on one staff for bathing. The resident was assessed to use a walker and a wheelchair as her main mobility devices. She was coded frequently incontinent of bowel and bladder. She was assessed with [REDACTED]. She was assessed for trouble falling asleep occurring 7-11 days during the assessment period. The resident was assessed to be 62 inches in height (5.16 ft) and weight at 161 pounds (lb). The resident was coded to receive an antipsychotic 5 out of 7 days and an antidepressant 3 out of 7 days. She was coded actively receiving speech, physical and occupational therapy. The resident was not identified to have had any falls in the last 6 months prior to admission. The MDS indicated a family member or significant other participated in the assessment. The Care Area Assessment (CAA) Summary triggered care areas to include cognitive loss/dementia, visual function, communication, urinary incontinence, falls and nutritional status. Mood and behavioral symptoms did not trigger. Assessment of Risk for Falls dated 9/4/15 scored Resident #15 at a 9 (7-18 indicated high risk for falls). The notation at the bottom of this assessment indicated if, in the judgement of the assessor, the resident is at risk, then the appropriate Protocol should be followed. She was assessed as a candidate for timed toileting. The Interim Care Plan dated 9/4/15 identified the resident was at risk for falls related to weakness. The goal the staff set for the resident was that she would not sustain injury related to fall over the next 30 days. Some of the approaches the staff would implement to accomplish this goal included place call bell within reach, cue for safety awareness, assist for toileting and transfers as needed and keep environment safe. The care plan dated 9/17/15 identified the resident had an actual fall and remained a potential for falls related to anemia, dementia, high blood pressure, vision deficit, use of psychotropic and impaired mobility. The goal set by the staff for the resident was that she would be free of complications and injuries related to falls through the next review. Some of the interventions added included safety equipment as ordered, therapy evaluation for decline in function, give resident verbal reminders not to ambulate or transfer without assistance, low bed when the resident is in the bed (a date of 9/4/15 was entered beside this intervention), floor mats at bedside (a date of 9/17/15 was entered beside this intervention), hipste

Based on observation, clinical record review, facility documentation and staff interviews the facility staff failed to identify, assess, and provide appropriate treatment and services to achieve and maintain as much normal urinary function as possible which resulted in harm for a resident with an external condom catheter as evidenced by a Stage III penile pressure area for 1 of 14 Resident's in the survey sample, Resident #101. The facility staff failed to immediately upon Resident #101's admission on 10/20/15 to identify, assess, and provide appropriate physician orders, treatment and nursing services to achieve and maintain as much normal urinary function as possible for an external condom catheter. The resident developed a Stage III penile pressure area resulting in harm. The findings included: Resident #101 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED].*[MEDICAL CONDITION], *[MEDICAL CONDITION], and *Arthritis. *Hypertension: a common disorder that is a known cardiovascular disease risk factor, characterized by elevated blood pressure over normal values of 120/80 mmHg (milligrams of mercury) in an adult. *[MEDICAL CONDITION]: a decrease in quality hemoglobin (a complex protein-iron compounding the blood that carries oxygen to the cells from the lungs and carbon [MEDICATION NAME] away from the cells) in the blood to levels below normal range of 12 to 16 for women. *[MEDICAL CONDITION]: a type of [MEDICAL CONDITION] transmitted most commonly by blood transfusion or percutaneous inoculation. *Arthritis: any [MEDICAL CONDITION] condition of the joints, characterized by pain, swelling, heat, redness, and limitation of movement. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. The most recent Minimum Data Set (MDS) assessment was an Admission 5 day assessment with an Assessment Reference Date (ARD) of 10/26/15 with a Brief Interview for Mental Status (BIMS) of a 15 out of a possible 15 which indicated the resident was cognitively intact and capable of daily decision making. On the MDS under Functional Ability Resident #101 was independent with setup help only for eating, indicating he was able to use his hands. Under Bowel and Bladder for urinary continence for section H0300 Resident #101 was coded as a 9 indicating (not rated, resident has a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days). Under Section M Skin Conditions the resident was coded to have 1 Stage III unhealed pressure ulcer. According to the MDS a Stage III Pressure Ulcer is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Resident #101's medical record review revealed documentation that was faxed to the skilled nursing facility from the discharging hospital for review on 10/20/15 at 8:11 a.m. and 8:12 a.m. The discharging hospital progress notes documented in part, read as follows: [MEDICAL CONDITION] MECHANISM: 10/18/15 at 16:42 (4:42 p.m.) Texas Cath (catheter) in place. 10/19/15 at 8:26 a.m. External Urinary Device. 10/19/15 at 18:33 (6:33 p.m.) Texas Cath in place. 10/20/15 at 00:43 (12:43 a.m.) Texas Cath in place. Resident #101 was admitted to the skilled nursing facility on 10/20/15 at 5:30 p.m. evidenced by the admitting nursing note written by LPN (Licensed Practical Nurse) #2. The admitting nursing note documented in part, read as follows: 10/20/15 5:30 p.m. Received resident sitting up in bed, arrived via stretcher and family at side. Resident alert and answers questions appropriately. Resident moves all extremities. Resident has dinner and ate 100% (percent). Resident oriented to room and use of call light, understanding verbalized. Resident complains of pain to L (left) arm and weakness noted with movement. Resident had orders verified, PT (Physical Therapy), OT (Occupational Therapy), ST (Speech Therapy) to screen, Tx (treat) and eval (evaluate). The Nursing Admission assessment dated [DATE] at 7:30 p.m. for Resident #101 completed by LPN #2 under Elimination-was marked for Bladder Incontinence Occasionally. Under Appliances and Programs-was marked with an X External (condom) Catheter. Medical record review revealed Risk Assessments for Resident #101 completed by LPN #2 on 10/20/15. Resident#101's Risk Assessments completed on 10/20/15 by LPN #2 documented in part, read as follows: Assessment for Bowel and Bladder Training Mental Status = 0 indicates Intact General Heath = 0 indicates Stable Mentally Aware of Tolieting Needs =1 indicates Usually Condition of skin on genital/perineal =0 indicates No Redness Continent of Urine = 2 indicates Stress Incontinence Predisposing Factors = 0 indicates None Assessment of Pressure Sore Potential Incontinent = 2 indicates daily (choices were Never/Catheter, Less than Daily, Daily, or Total). Pressure Sore =0 indicates None Assessment of Nutritional Risk Pressure Ulcers = 0 indicates None Assessment of Risk for Dehydration Hand Dexterity Problems = 0 indicates Can Pick up and handle cup/glass Assessment of Contracture Risk Upper Extremities = 0 indicates Full Use Assessment of Risk for Falls Incontinence = 2 indicates Daily On 11/6/15 at 3:15 p.m. an interview was conducted with LPN #2. LPN #2 was asked the process when admitting Resident #101 on 10/20/15. LPN #2 stated, He came in and I was finishing up with my shift. I gave a verbal introduction to him, he was sitting on the bedside. I asked him some questions, like food preferences. I didn't do a body check he was eating his meal. I did ask him if he needed help going to the bathroom and he said no. His family member said he was weak in the hospital. I didn't notice he had a catheter. I did the admission note and had the orders verified. When asked if the Bowel and Bladder Assessment and the other Risk Assessments when done, LPN #2 stated, Yes, I did. When asked how she missed assessing the condom catheter LPN #2 stated, I think I didn't do the head to toe assessment. I think I passed that on for the next shift to do. If someone comes in with a condom catheter the person who got the verbal report from the hospital should have alerted me. If someone has a catheter we would determine if it's needed and get and order for it or discontinue it. LPN #2 was asked if this was what had happened for this resident and LPN #2 stated, No. When asked if a full body assessment was done prior to completing the Risk Assessments and verifying the admission orders [REDACTED]. I was just helping out. The Interim Admission Care Plan for Resident #101 completed on 10/20/15 by LPN #2 and reviewed by Unit Manager RN (Registered Nurse) #1 on 10/21/15 under Resident has a urinary catheter R/T (related to), had no boxes checked and was not addressed. Unit Manager RN (Registered Nurse) #1 informed the surveyor that a chart review had been completed by her on 10/21/15 for Resident #101. A copy of this chart review was presented to the surveyor documented in part, as follows: Skin- condom cath to be add. (addressed) by MD (medical doctor). The Weekly Skin Assessment for Resident #101 was reviewed by the surveyor that was completed on 10/21/15 by LPN #1, the skin assessment nurse. The Weekly Skin Assessment for Resident #101 dated 10/21/15 documented in part, read as follows: 4. Condom foley cath. On 11/5/15 at 1:00 p.m. an interview was conducted with the skin assessment nurse LPN #1. LPN #1 stated, I noted he had a condom catheter when I did his skin assessment on 10/21/15, and I have maintenance orders to put in place on what I find. I went to the nurse's desk and told LPN #4 and Unit Manager RN #1 that I couldn't write maintenance orders for the condom catheter because we don't have any. I told them to find out why he had the catheter and if it was not needed to get is discontinued, because we don't carry them (condom catheters). Medical record review of Resident #101's physician signed admission orders [REDACTED]. The physician progress notes [REDACTED].#101's attending physician dated 10/21/15 at 16:30 (4:30 p.m.) which included past medical history, diagnoses, a physical exam, and problems, did not reveal any documentation the condom catheter had been assessed by the physician. Resident #101's Occupational Daily Treatment Note dated 10/22/15 was reviewed, documented in part, it read as follows: Note: Trained pt (patient) to manage catheter through 2 leg holes before starting to don them- pt was able to grasp pants with RUE (right upper extremity) and start one leg/mod A (moderate assistance) to complete the task including hiking them over hips in stance. A facility document titled, Physician Non-Emergency Log was reviewed by the surveyor. The Physician Non-Emergency Log documented in part, read as follows: Date-10/23 (beside of the date were the initials of the Nurse Practitioner) Rm (room)#/Name- Resident #101 Concern- D/C (discontinue) condom cath? Nurse- SB (LPN #4) MD (medical doctor)- blank Comments- blank LPN #4 was asked to explain the Physician Non- Emergency Log to the surveyor. LPN #4 stated, We use this form to update the doctor or nurse practitioner about concerns with the residents. They look at it, sign it off, and write the orders. On 11/6/15 at 3:00 p.m. an interview was conducted with the Nurse Practitioner who had initialed the Physician Non-Emergency Log for Resident #101 on 10/23/15. The Nurse Practitioner stated, I signed the log off on 10/26/15 not 10/23/15 after (name) RN #2 Wound Nurse came to me and told me the resident had no indication for the catheter. I told her (RN #2 Wound Nurse) to d/c (discontinue) it. When asked if she/he wrote the order to discontinue the catheter, the Nurse Practitioner stated, No, I told the (name) RN #2 Wound Nurse she could write it. Resident #101's Nurse's Notes were reviewed from 10/20/015 forward. Resident #101's Nurse's Notes documented in part, read as follows: 10/21/15 at 5:22 p.m. Foley catheter intact and draining yellow urine. 10/23/15 at 1:38 a.m. residents foley in place and draining. 10/23/15 at 3:26 a.m. Bladder- Urinary Continence External Catheter 10/23/15 at 10:45 a.m. Foley checked, Condom cath present, pt (patent) draining clear yellow urine. Output WNL (within normal limits) 10/25/15 at 6:00 a.m. Bladder-Continent, External Catheter, Urine Clear/Yellow Condom catheter for drainage of clear yellow urine. (This entry was by RN #2 Wound Nurse). 10/25/15 at 10:43 a.m. Bladder-Urine Clear/Yellow, Urinary Continence Condom Catheter. 10/25/15 at 10:52 a.m. Condom cath. patent draining clear yellow urine with output WNL (within normal limits). 10/26/15 at 5:29 a.m. Bladder-Urinary Continence Continent Resident refused condom cath and urinated in urinal. Residents condom cath came off and requested urinal. Resident urinated in urinal without difficulty. 10/26/15 at 6:46 p.m. Condom catheter was discontinued and resident was assessed by this RN wound nurse with an open area to the penis area from removal of catheter (5.2 x 0.5 x 0.2 cm (centimeters). Wound bed is pink in color and absent of any necrosis, bleeding, odor, [DIAGNOSES REDACTED], purulence or swelling. Pain is elicited assesses as 4 out of 10 by this RN. (Name), N.P. (nurse practitioner) was notified of wound status and new tx (treatment) orders were obtained and initiated with [MEDICATION NAME] oint. (ointment) and cover drsg. (dressing) twice daily and prn (as needed) to protect. 11/4/15 at 8:23 a.m. Wound rounds and assessment completed with (Name) Wound Consult Specialist, on 10/29/15 and assessment indicates the following: Stage III pressure ulcer of Distal Penis measuring (2.0 x 0.4 x 0.1 cm) with 0.80 cm sf. (surface area) area with 100% res-pink colored granulation tissue and grains a light amount of serous exudate without odor. Condom catheter is d/c (discontinued) and resident voids without c/o (complaint of) pain or difficulty in urinal. Wound progress is improved as evidenced by decreased wound sf. area and depth. See Weekly Wound Documentation Progress Sheet. Margins are intact. Tx (treatment) is changed to [MEDICATION NAME] qshift (every shift) without drsg (dressing). Resident #101's Weekly Wound Documentation Progress Sheet was reviewed and documented in part, as follows: Type of Wound: Pressure Date Wound First Identified: 10/26/15 In-house Acquired on 10/26/15 Wound Location: #1 Distal Penis Condom Catheter D/c'd (discontinued) Date: 10/26/15 Stage (pressure ulcers only): III LxWxD (length x width x depth): 5 Wound Base: 100% Granulation Drainage/Odor: Scant, Serosanguineous Wound Edges: Intact Wound Progress/Pain: New site, Pain associated with wound: Yes Managed with: Prn (as needed ) pain med. (medication) Nurse Initial: (Initials) RN#2 Wound Nurse Resident #101's Wound Care Specialist Initial Evaluation dated 10/29/15 completed by the Wound Doctor documented in part, read as follows: History of Present Illness: Chief Complaint: Patient has a wound on their penis. HPI (history and physical ) Statement: At the request of (name attending physician), this [AGE] year old male was seen and evaluated today. He presents with a stage 3 pressure wound of the distal penis of at least 1 days duration. There is light serous exudate. There is no indication of pain associated with this condition. Physical Exam: Skin: Groin/Buttock: Wound Extremities: Left upper extremity muscle strength: Moderate Strength Right upper extremity strength: Moderate Strength Stage 3 Pressure Wound Of The Distal Penis: FOCUSED WOUND EXAM (Site1) ETIOLOGY (QUALITY): Pressure MDS3.0 STAGE: 3 DURATION: > 1 days WOUND SIZE: 2 x 0.4 x 0.1 SURFACE AREA: 0.80cm EXUDATE: Light Serous GRANULATION TISSUE: 100% Assessment and Plan: STAGE 3 PRESSURE WOUND OF THE DISTAL PENIS - INITIAL EVALUATION Discontinue: Dry Protective Dressing-Once Daily, [MEDICATION NAME]-Once Daily Add: [MEDICATION NAME]-TID (three times a day) On 11/5/15 at 10:25 a.m. an interview was conducted with the Wound Care Physician. When asked what caused the Stage II penis pressure ulcer and if it had healed, the Wound Care Physician stated, The Stage III pressure area to the resident's penis was caused by the condom catheter and it is resolved, not healed. The wound is closed but the new skin remains fragile and therefore it will take months to fully heal. On 11/5/15 at 10:15 a.m. an interview was conducted with Resident #101. Resident 101 was asked if he was admitted to the skilled nursing facility with the condom catheter and if the staff removed it daily to provide perineal care. Resident 101 stated, Yes I came from the VA (veterans administration) hospital with the catheter and no they didn't take it off for my baths. When asked when did he notice something was wrong, Resident #101 stated, It came off and the nurse went to change it, then I went to pee and it came off again then it was too sore to put it back. When asked if any other doctor other that the Wound Doctor looked at his penis, Resident #1 stated, I don't think so she was the only one. When asked if your penis hurt when the pressure area was discovered, Resident #1 stated, It hurt, like the devil. Resident #101's Comprehensive Care Plan dated 10/26/15 was reviewed and documented part, read as follows: Problem Onset: Stage III Pressure Ulcer to penis 10/26/15. Approaches: Condom Catheter was removed and Discontinued. Comments: Wound Doctor consult for TX (treatment) management of wound penis pressure ulcer. Resident #101's Activity of Daily Living Flow Sheets were reviewed by the surveyor. Activity of Daily Living Flow Sheets documented in part, read as follows: Bladder: Indicate urinary function using the following codes: C=Continence I=Incontinence #=Enter quantity per shift Nights Day Evening 10/21/15- no entry C/600 cc (cubic centimeter) C/800 cc 10/22/15- I/1450 cc C/500 cc C/800 cc 10/23/15- no entry C/600 cc C/ no entry 10/24/15- no entry C/600 cc C/400 cc 10/25/15- I/800 cc C/700 cc C/no entry 10/26/15- no entry C/C C/2 10/27/15- no entry C/C C/800 cc 10/28/15- no entry C/C C/2 10/29/15- no entry C/C C/240 cc On 11/6/15 at approximately 2:00 p.m. an interview was conducted with the Director of Nursing (DON). When asked to explain the process when a new admission enters the facility, the DON stated, Either the DON, Unit Manager, or Desk Nurse take off the orders from the transfer summary. Then the Admission assessment is completed and the Risk Assessments are done. When asked to explain how to do an admission assessment, the DON stated, Go in and see the patient, talk to them, visualize the patient, ask questions. Notice anything visible, notice if they have IV's (Intravenous Lines), catheters, anything I can visualize. Get vital signs. After the nursing assessment the nurse goes down to do a full body assessment. You can't do the risk or skin assessments without a full body assessment. When asked to explain a full body assessment she stated, You look at the full body, everything. Turn them from side to side, head to toe, every crack and crevice. Everything they see they document, I don't want to own it. The DON was asked if the nurses should have seen the condom catheter, she stated, I don't think they looked at the patient prior to doing the assessment. Yes, I would have expected them to have seen the catheter and to have added it to the admission orders [REDACTED]No, there was no need for a condom catheter. It should have been discontinued on admission and followed up on before 10/23/15. When asked about the resident's daily perineal care she stated, During ADL's (activities of daily living) care they (nursing assistants) should remove the condom catheter everyday so the penis can be cleaned. We would have seen the skin breakdown if we were doing daily catheter care. When asked if the Stage III penis pressure ulcer could have been avoided she stated, If it would have been taken care of on admission yes, it was unnecessary. The DON stated, It caused an injury. When asked if this injury to the resident's penis was harm, the DON stated, Yes. The DON was then asked if staff had managed the care and services of the resident's catheter? The DON stated, No. The facility policy titled, Admission Assessment and Follow Up: Role of the Nurse revised September 2012 documented in part read as follows: Purpose The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. Steps in the Procedure 7. Conduct an admission assessment (history and physical), including, a. A summary of the individual's recent medical history, including hospitalization s, acute illnesses, and overall status prior to admission. c. A list of active medical [DIAGNOSES REDACTED]. those most related to reasons for admission to the facility and those that are affection function, behavior, cognition, nutrition, hydration, quality of life, likelihood of functional recovery, and ability to participate in activities and to socialize. 8. Conduct a physical assessment, including the following systems: i. Genito-Urinary j. Skin 12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and to obtain admission orders [REDACTED] Documentation The following information should be recorded in the resident's medical record: 1. The date and time the assessment was performed. 2. The name and title of the individual who performed the procedure. 3. All relevant assessment data obtained during the procedure. 4. How the resident tolerated the assessment. 5. Orders obtained from the physician. 6. The signature and title of the person recording the data. The facility policy titled, External Male Catheter (Condom Catheter) revised October 2010 documented in part read as follows: Purpose The purpose of this procedure is to prevent urinary tract infections and skin breakdown in an incontinent resident. Preparation 1. Verify that there is a physician's order for the procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. Equipment and Supplies 1. Condom catheter in size appropriate for resident. Steps in Procedure 7. Wash the resident's perineum thoroughly with soap and water. Rinse the area well and towel dry. The facility policy titled, Perineal Care revised October 2010 documented in part read as follows: Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure 10. For a male resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area starting with the urethra and working outward. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) Wash and rinse the urethral area using a circular motion. Continue to wash the perineal area including the penis, scrotum, and inner thighs. c. Thoroughly rinse perineal area in the same order, using fresh water and clean washcloth. (Note: If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.) Documentation The following information should be recorded in the resident's medical record. 1. The date and time that perineal care was given. 2. The name and title of the individual giving the perineal care. 3. Any discharge, odor, bleeding, skin care problems or irritation, complaints of pain or discomfort. 4. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. A pre-exit interview was conducted with the Administrator, Director of Nursing, and the Regional Nurse Consultant on 11/6/15 at approximately 6:00 p.m. where the above findings were shared. When the facility group was asked what they would have expected their nurse to have done the Regional Nurse Consultant stated, For the nurse to have done a head to toe assessment and call the doctor and get an order to discontinue the catheter. I would expect nursing to provide the care he required. Prior to exit no further information was provided.