Every finding on record at Dublinair Health & Rehab

Based on staff and family interviews, record reviews, and a review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, the facility failed to provide an environment free from accident hazards for one of one Residents (R) (R3) related to a fall. On 12/12/2025, actual harm occurred when Licensed Practical Nurse (LPN) FF blew an air horn on C hall (R3 was ambulating at the time of the air horn activation), which startled R3 and increased ambulation, resulting in a fall. R3 sustained an acute comminuted intertrochanteric fracture of the right femur. R3 was hospitalized on [DATE] and underwent an operative fixation (a surgical repair for broken bones) as a result of the fall. Findings include:Review of the Electronic Medical Records (EMR) for R3 revealed resident was admitted into the facility on 3/8/2023 with a diagnosis that included: dementia in other diseases classified elsewhere, Alzheimer's Disease, unspecified severity with mood disturbance, and depression.Review of the most recent Significant Change Minimum Data Set (MDS) dated [DATE] documented that R3 had a Brief Interview of Mental Status (BIMS) of 99, indicating severe cognitive impairment. Further review revealed that R3 displays signs of wandering daily, no recent behaviors, dependent for bathing, dressing and personal hygiene.Review of R3's care plan dated 10/23/2025 revealed that R3 would be free of falls through the review date of 10/14/2025 with no revision date. Interventions include refer R3 for physical therapy evaluation (PT) as needed, monitor the changes in the condition that may warrant increased supervision/assistance and notify the physician, refer to restorative nursing programs as needed, evaluate the effectiveness and side effects of psychotropic drug(s) for possible decrease in dosage/elimination of drugs, encourage the use of non-skid footwear as tolerated and low beds with fall mats.Review of R3's facility records revealed witness statements detailing the fall of R3 that occurred on 12/12/2025. Witness statement #1 received from Certified Nursing Assistant (CNA) LL revealed that she witnessed Licensed Practical Nurse (LPN) FF blowing an air horn behind R3 going down the hall. She reported it startled R3 and she was walking fast. CNA LL stated she kept telling R3 to slow down but by the time she was able to get close to her, she had fallen. LPN FF was trying to get R3 to walk but I sat her down in her Geri chair. At the end of my shift, she was still sitting in the Geri chair.Witness statement # 2 received from CNA OO revealed that at approximately 11:00 p.m., I assisted another CNA with changing R3. During care, we both noticed a bruise on her right hip. We immediately notified LPN FF. She came in and completed an assessment. Afterward, we ensured that R3's bed was in the lowest position before leaving the room.Witness statement # 3 received from LPN NN revealed on 12/12/2025, she was standing at Nurses Station 1 with the Consultant Pharmacy Representative receiving medications when an air horn was blown by LPN FF. After the air horn was blown, R3 was observed moving past the nurses' station at a fast pace. LPN NN returned to Nurses Station 2 to put the received medications away. She was not made aware of a fall until several hours into the shift and did not witness the fall.Telephone interview with LPN FF on 02/04/2026 at 3:43 PM. She stated that on the evening of the incident, R3 was ambulating from D and E Hall toward C Hall with CNA LL. LPN FF revealed that CNA LL was instructing R3 to slow down, as the resident was walking at a fast pace. LPN FF stated that she activated an air horn; however, she denied that the air horn was related to the R3's fall and stated it was intended to startle other staff members, including LPN MM. LPN FF reported that R3 was walking quickly but denied that she was running at any time. She stated that after CNA LL released the resident's hand, R3 continued down the hallway and subsequently fell over lifting equipment that was positioned in the hallway. LPN FF stated that R3 was found on the lip of the equipment, which is where staff assisted her after the fall. LPN FF stated that she had been counseled by administration regarding the incident and was instructed not to bring or use an air horn at work and not to record or post videos while at work. LPN FF stated that she would not engage in these actions again.Telephone interview on 2/4/2026 at 6:04 PM with complainant revealed that on the evening of December 12th at 7:51 p.m., she received a call from LPN FF stating that R3 had taken off running, fallen, and hit her head. She asked if I wanted her sent to the emergency room. The complainant revealed that R3 has severe dementia and is unable to speak for herself, feed herself, or make decisions of any kind. The last time she was taken to the emergency room (ER), she became extremely combative and distressed. After that incident, the doctor and I agreed that, if possible, she should be monitored at the nursing home rather than sent to the ER. Because of this, I told the nursing home not to send her to the ER and to monitor her, as I was unable to get there immediately. They informed me that she seemed okay, her vital signs were good, she was acting like herself, and she had a goose egg on her head. The complainant stated at approximately 1:30 AM a family member received a phone call from the emergency room informing her that R3 was being admitted . We were told that she had a broken hip and would require surgery, and that the surgery was scheduled to take place the following morning.Review of hospital records dated 12/13/2025 R3 was seen at the local emergency room (ER) related to a fall in which R3 hit her head, resulting in a large hematoma. Initially, the family did not desire transport to the ER, however R3 was unable to bear weight on her right lower extremity and complained of pain. A right hip and femur x-ray revealed an acute comminuted intertrochanteric fracture of the right femur. R3 was also positive for an acute urinary tract infection. An orthopedic surgeon was consulted, and a surgical fixation was completed on 12/13/2025. The procedure performed was right hip cehalomedullary nail placement with a reduction. R3 will follow up in two weeks for suture removal. R3 was discharged back to the facility on [DATE].An interview was conducted with CNA II on 2/5/2026 at 12:15 PM. CNA II stated that she was aware of the foghorn-related incident; however, her shift had ended before it occurred. CNA II stated that LPN FF had been blowing the foghorn throughout the day on the date of the incident; however, CNA II stated that the foghorn was not blown at her. Interview with LPN JJ on 2/5/2026 at 12:23 PM revealed that LPN FF stated that she blew a foghorn at LPN MM to scare him, which resulted in R3's fall. LPN JJ further stated that approximately two to three days after the fall, LPN FF blew the foghorn at her to scare her. An interview with the Administrator on 2/5/2026 at 2:03 PM revealed she received a call from LPN FF regarding a fall involving R3 on 12/12/2025. The Administrator stated she does not recall whether she was informed of a possible head injury at the time of the initial call. She reported that LPN FF advised that the R3's family had been notified and declined transport to the emergency room because the family was out of town. The Administrator stated that LPN FF called back later that night to report a bruise on the R3's hip discovered while changing her. States that LPN FF advised they were transporting R3 to the ER. The Administrator further revealed that on the following Monday, 12/15/2025, while in her office, she heard a foghorn being activated by LPN FF. She exited her office and took possession of the foghorn. Day-shift staff began reporting details surrounding R3's fall and advised that LPN FF had activated the foghorn at the time of the fall. The Administrator stated that according to staff reports, R3 was walking quickly on C Hall with CNA LL when LPN FF blew the foghorn. It appeared that the sound startled R3 significantly, causing her to walk faster, lose control, and subsequently fall. The Administrator confirmed that she believed this demonstrated poor judgment on the part of LPN FF. LPN FF was presented with the disciplinary report but refused to acknowledge it by signing. The Administrator interview revealed that no formal educational or in-service training was provided to LPN FF related to this incident; however, a verbal warning was issued.

Based on observations, staff, resident and resident representative interviews, and review of the facility's policy titled Care Plans, Comprehensive Person-Centered, the facility failed to develop a comprehensive person-centered care plan for one residents (R) (R3) related to heel boots. Additionally, the facility failed to develop a comprehensive person-centered care plan for one resident (R2) related to fall mats. This failure has the potential to place residents at risk for unmet needs and diminished quality of life. 1. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed, that A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.8. The comprehensive, person-centered care plan will: a include measurable objectives and time frames; include the resident stated goals upon admission and desired outcomes; Include incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on the residence strengths; Aid in preventing or reducing decline in the residence functional status and/ or functional levels. Review of the Electronic Medical Record (EMR) revealed R2 was admitted into the facility on 3/5/2025 with a diagnosis that included, but not limited to, mood disorder due to a known physiological condition with depressive features, fracture of unspecified part of left clavicle, initial encounter for closed fracture. Review of the most recent Significant Change Minimum Data Set (MDS) dated [DATE] documented that R2 had a Brief Interview of Mental Status (BIMS) of 07, indicating that the resident has cognitive impairment. (Section GG) revealed that the resident is dependent for all (Activities of Daily Living) ADL care. Review of the Physicians' orders for R2 revealed an order dated 12/31/2025 for the resident's bed to be low with fall mats Review of R2's care plan dated 12/29/2025 revealed it was not updated to reflect the physician's order requiring fall mats. Goals and interventions were not developed. Observation made on 2/3/2026 at 1:00 PM of R2 in bed with no fall mats. Observation made on 2/3/2026 at 5:30 PM of R2 in bed with no fall mats. Observation made on 2/4/2026 at 12:15 PM of R2 in bed with no fall mats. Observation made on 2/5/2026 at 9:15 AM of R2 in bed with no fall mats. An interview and observation on 2/5/2026 at 9:15 AM with the Director of Nursing (DON) revealed that R2's fall mats were not placed on the side of the bed or in the resident's room. The DON revealed that she expects the staff to follow all doctors' orders and that it be placed on the care plan. 2. Review of the EMR revealed R3 was admitted into the facility on 3/8/2023 with a diagnosis that included but not limited to anxiety disorder, chronic pain syndrome, mild protein- calorie malnutrition. Review of the most recent Significant Change Minimum Data Set (MDS) dated [DATE] documented that R3 had a Brief Interview of Mental Status (BIMS) of 99 indicating that the resident had severe cognitive impairment. Review of R3's care plan dated 10/23/2025 revealed it was not updated to reflect the physician's order dated 1/16/2026 requiring the resident to wear bilateral heel boots at all times, every shift. Goals and interventions were not developed. Review of the Physicians' orders for R3 revealed an order dated 1/16/2026 for the resident to wear bilateral heel boots at all times, every shift. Observation made on 2/3/2026 at 1:13 PM of R3 in her geri chair in her room and bilateral heel boots were not worn. Observation made on 2/4/2026 at 12:46 PM of R3 in her geri chair in her room and bilateral heel boots were not worn. Observation and interview on 2/4/2026 at 5:45 PM of R3 in her room, in her geriatic chair revealed bilateral boots were not being worn. Interview with oldest daughter revealed that bilateral boots are worn only on occasions, although the family has expressed concerns to the staff. An interview with Director of Nursing (DON) on 2/5/2026 at 1:52 PM revealed that her expectations if for staff to follow MD orders as written and that the care plan be updated as significant changes occur.

Based on observation, staff interview, and review of the facility policies titled, Food Storage Guidelines and Ice Maker Sanitation, the facility failed to ensure opened food items in the kitchen's dry storage area were securely wrapped, labeled and dated. Also, the facility failed to discard refrigerated food items by expiration date in one of two freezers. In addition, the facility failed to maintain sanitary conditions for one of one ice machine units. The deficient practice had the potential to affect 92 out of 105 residents receiving an oral diet.Findings include: Review of facility's policy titled Food Storage Guidelines, dated 3/2024, under the section titled Procedure revealed, 2. Non-Perishable food will have the following dates available: Delivery Date and once opened, will have the Open Date. 4. Prepared Foods upon delivery will have the following dates: Delivery Date and once opened, will have the Open and Discard Date.Review of facility policy titled Ice Maker Sanitation, revised dated 2/2025, under the section titled How Often Should Ice Supplies be Cleaned and Sanitized? revealed, Ice Cooler/Chest= Weekly or more often if it is the facility protocol.During a tour of the kitchen on 9/12/2025 at 7:42 am, with [NAME] CC, the following was observed:The dry storage area revealed open, unlabeled, and undated items that consisted of: one 5 (five) lb. (pound), bag of grits, one 160 oz. (ounce) bag of elbow macaroni and spaghetti noodles, one 5 lb. bag of egg noodles, and one 5 lb. bag of a yellowish dry mix identified by [NAME] CC as breadcrumbs, along with one 2 (two) oz. gourmet coffee blend.The reach-in refrigerator contained one 6 (six) qt. (quart) Bacon-[NAME] with an expiration date of 9/11/2025. Interview with [NAME] CC during this time revealed that she had checked for expiration dates, past usage, and expired foods, during the delivery from the truck the previous day.Further observation revealed the ice machine had a black/reddish-like substance at the ice base and underneath it. A visual inspection of the interior revealed a white substance near the bolt hinge which was missing a bolt. The outer parts of the interior exhibited various particles. Interview with [NAME] CC revealed that the Maintenance Director was responsible for the cleaning of the ice machine.An interview with the Maintenance Director conducted on 9/12/2025 at 8:29 am, confirmed that he had not completed the monthly cleaning for this month. Additionally, a review of the cleaning log indicated that the last deep cleaning occurred on 8/15/2025.An interview conducted on 9/14/2025 at 7:58 am, with [NAME] CC revealed that the Dietary Manager, along with the two cooks, was tasked with labeling and dating all food items on Mondays and Thursdays during delivery. However, the cooks and dietary staff who stored any leftover food were also responsible for labeling and dating it. [NAME] CC confirmed that the dates that are to be recorded should include the date received and the open date but expressed uncertainty regarding the discard date. [NAME] CC acknowledged that the failure to properly store or label food could lead to food poisoning.An interview held on 9/14/2025, at 8:03 am, with the Dietary Manager (DM) revealed that both the cooks and the DM herself were responsible for verifying the labeling and dates on all food items. The DM stated that we make an effort to check the food items consistently throughout the day and on a daily basis; however, this was an oversight this time, which could present a risk of someone falling ill. The Dietary Manager revealed that the dates should have the date received, the date opened, and if the manufacturer's date was not available, they would put a discarded date.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Activities of Daily Living (ADL) Supporting, the facility failed to ensure nail care was provided for one of four sampled Residents (R) (R96) reviewed for ADLs.Findings include:A review of the facility's policy titled, Activities of Daily Living (ADL) Supporting dated March 2018 under the section titled Policy Statement revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.A review of the electronic medical record (EMR) revealed R96 was admitted to the facility with a diagnosis that included but was not limited to, age-related physical debility.A review of the admission Minimum Data Set (MDS) assessment dated [DATE] for R96 revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment and Section GG (Functional Abilities and Goals) revealed, R96 was dependent on staff for personal hygiene care.A review of the care plan dated 8/28/2025 revealed R96 required assistance with ADLs that included interventions to provide assistance with ADLs as needed.During an observation and interview on 9/12/2025 at 9:39 am revealed R96's fingernails were long with a dark substance underneath them. R96 stated his fingernails needed to be trimmed down and that he had informed a Certified Nurse Assistant (CNA) about cutting them.During an interview on 9/13/2025 at 1:22 pm with CNA AA confirmed R96 fingernails were long, needed to be trimmed and had a dark substance underneath them. She revealed that if R96 was assigned to her she would have taken care of his nails.During an interview on 9/13/2025 at 1:27 pm with Licensed Practical Nurse (LPN) BB confirmed R96's finger nails should be trimmed and cleaned during care. LPN BB revealed that at the nurse's station there was a check-off list with residents' names that they should be following to ensure nail care was completed. During an observation and interview on 9/13/2025 at 1:31 pm with the Director of Nursing (DON) confirmed R96's nails were long with a dark substance underneath them. The DON stated that the CNAs were supposed to check and perform nail care during baths.

Based on observations, interviews, and review of the facility's policy titled Safe and Homelike Environment, the facility failed to provide a provide a safe, clean, comfortable and homelike environment on two of six halls (A hall and D hall). Specifically, the facility failed to ensure rooms in four rooms (A3,A12, D1, and D2) were free of scuffed and peeling paint on the walls, holes and cracks in the walls, missing baseboards, sheet rock and baseboards in disrepair.Findings include: Review of the facility's undated policy titled Safe and Homelike Environment under the section titled Policy: revealed, In accordance with the resident's rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk. 1. Observation on 9/12/2025 at 10:05 am in room D1 revealed scuffing and peeling paint on the dry walls, along with two large circular patches, gouged, and uneven sheet rock, each approximately twelve inches in diameter, situated at the head of bed B. The previously patched areas of sheet rock remain in disrepair. Further observation revealed that the missing baseboard was discovered caught under the wheels of resident B bed. 2. Observation on 9/12/2025, at 10:16 am in room D2 revealed one of the walls contained a hole or gouge measuring approximately thirty-six inches in the sheetrock, located at the head of resident A bed near the baseboard. Observation and interview conducted on 9/13/2025 at 1:11 pm with the Administrator in rooms D1 and D2 confirmed the findings of scuffing and peeling paint on the dry walls, sheet rock in disrepair, and missing baseboard. An interview conducted on 9/14/2025, at 8:09 am with the Maintenance Director (MD) confirmed that each department head was accountable for inspecting the residents rooms on each hallway. If any issues were observed, they were recorded on the form or in the Maintenance and Equipment book request. The Maintenance Director noted that he attempts to delegate tasks between himself and his assistant; however, he often finds himself in multiple locations simultaneously, striving to fulfill work orders. An interview conducted on 9/14/2025 at 8:42 am, with the Medical Records Director (MR) revealed that she was tasked with completing rounds on the D hall. However, she mentioned that she did not remember observing or being responsible for inspecting room D1. The MR noted that she only recalled inspecting room D2, where she confirmed the presence of a scuffed wall, peeling paint, and damaged sheetrock. Furthermore, the MR explained that she discussed her findings during morning meetings attended by all department heads, including the Maintenance Director. An interview conducted on 9/14/2025, at 8:53 am with the Administrator revealed that each department head was responsible for completing Angel Rounds/Compliance Rounds, which encompasses the observation of ceiling tiles, walls, bathroom tiles, and essentially the entire room. The Administrator confirmed that during the morning meeting, the findings were discussed, and the observations made during the tour should have been previously identified. The Administrator explained that there were no risks; however, the observations impact the residents homelike environment. 3. Observation on 9/12/2025 at 11:00 am in room A3 revealed a crack in the wall approximately 13 inches long on the right side of the bathroom door panel. 4. Observation on 9/13/2025 at 12:15 pm in room A12 revealed that the baseboard on the side of the resident in A bed was hanging off the wall and needed repair. An interview conducted on 9/14/2025 at 9:45 a.m. with the Supply Clerk revealed that she was tasked with completing rounds on half of A hall. However, she mentioned that she did not observe the wall being cracked in room A3. She confirmed that she should have noticed the crack and reported it in TELS (platform used maintenance work orders) for repairs. The supply clerk confirmed that the baseboards in room A12 also needed to be repaired.

Based on staff interviews, record review, and a review of the facility policy titled, Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to submit a PASARR Level II for one of two residents (R) (R1) reviewed for a mental illness diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R1. Findings include: A review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, dated 12/19/2022, revealed the Policy stated, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. The Policy Explanation and Compliance section stated, 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. A review of the electronic medical record (EMR) revealed that R1 was admitted to the facility with diagnoses including, but not limited to, schizophrenia, psychosis not due to a substance or known physiological condition, mood disorder due to known physiological condition, major depressive disorder, and anxiety disorder. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed section A (Identification Information) documented the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, section I (Active Diagnoses) documented schizophrenia, and section O (Special Treatments and Programs) documented R1 did not receive psychological services. A review of the quarterly MDS dated [DATE] revealed section I (Active Diagnoses) documented schizophrenia, and section O (Special Treatments and Programs) documented R1 did not receive psychological services. A review of the EMR revealed a PASRR Level I request dated 12/12/2022 without schizophrenia marked on the form. A further review revealed there was no re-submission for a PASRR Level I after the facility coded schizophrenia on the MDS. In an interview on 8/21/2024 at 1:03 pm, the Social Service Director (SSD) stated all residents were admitted to the facility with a least a PASRR Level I. The SSD further stated she was responsible for checking the admissions for qualifying diagnoses that would potentially trigger a PASRR Level II. She confirmed that R1 did not have PASRR Level II and had been admitted from a hospital. The SSD confirmed that she was aware R1 had a diagnosis of schizophrenia but felt her hallucinations and delusions were stable. The SSD further stated she did not feel R1 needed a referral for psychological services because the issues she was experiencing were normal for her. In an interview on 8/21/2024 at 1:12 pm, Certified Nursing Assistant (CNA) AA revealed R1 had behaviors such as cursing and speaking inappropriately to staff while they were caring for her roommate. She stated these behaviors seem to not have any triggers. In an interview on 8/21/2024 at 1:16 pm, Licensed Practical Nurse (LPN) BB stated R1 didn't always have behaviors but did have mood swings. LPN BB further stated R1 was not aggressive. However, she yelled out and exhibited attention-seeking behaviors. In an interview on 8/21/2024 at 1:28 pm, LPN Unit Manager CC verified R1 had a diagnosis of schizophrenia and stated the resident had episodes of hollering out for no apparent reason. LPN UM CC stated that R1's behaviors have been communicated to the SSD. LPN UM CC further stated she was not involved in the process of requesting PASARR Level II's. In an interview on 8/21/2024 at 1:45 pm, the Director of Nursing (DON) verified that R1 had inappropriate behavioral outbreaks, delusions, and hallucinations. The DON further stated she did not have knowledge of the criteria for PASARR Level II's because the SSD was solely responsible for that process.

Based on record review and staff interview, the facility failed to notify the family of resident (R) (R#1) of a significant change in condition which required the resident to be transferred to the hospital, from a sample of 10 residents. Findings include: R#1 was admitted to the facility on [DATE] with the following but not limited Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 9/25/21 Nurses Note revealed staff noted the resident was lethargic with fowl smelling black stools. The Nurse Practitioner was called with orders to transfer to the emergency room for evaluation. It further noted the writer attempted to contact the family on both numbers with no success. There was no documentation the staff had left a voicemail or attempted to call the family again at a later time. During an interview with the resident's family on 12/15/21 at 2:29 p.m., she stated no one from the facility contacted her or her uncle regarding her brother being transferred to the emergency room . She also stated she still has not heard from the facility to tell her to come and get her brother's personal belongings since he passed away at the hospital. She stated a doctor from the hospital was the one who called to tell her the resident was in the hospital in critical condition. During an interview with the Administrator on 12/8/21 at 10:00 a.m., she stated the staff told her they called the family and left message but did not document they left a message. She also stated there was documentation the staff attempted to call the family again.

Based on record review and interviews, the facility failed to ensure that the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. A review of R#66's medical record revealed a POLST dated 12/7/2020 with a resident's representative signature and one physician's signature. The POLST was to allow a natural death for the resident. A review of the quarterly Minimum Data Set (MDS) dated [DATE] showed that the resident had a Brief Interview for Mental Status (BIMS) of 11, indicating the resident had moderately impaired cognition. During an interview on 8/26/21 at 10:37 a.m., R#66 stated that her POA makes financial decisions for her, but she was unsure if her POA has POA of her health treatment. During an interview on 8/26/21 at 12:48 p.m., the Business Office Manager (BOM) stated that the POA paperwork was usually done with the admission packet. The BOM stated that the POA or the resident signed the POLST. Once the POLST had been signed by the POA or resident (if capable), then the physician signed, and it went into the nurse's chart. The BOM stated that she was unaware of where the actual POA forms were. During an interview on 8/26/21 at 3:08 p.m., the Administrator stated that she did not have the POA form for R#66. 2. A review of R#63's medical record revealed a POLST dated 10/23/2020 for a Do Not Resuscitate (DNR) order with a signature by a resident's representative and only one physician's signature. The POLST form had a sticky note stating that there was no POA. Attempted to interview R#63 at 10:32 a.m., but the resident was confused. A review of the quarterly MDS dated [DATE] showed the resident had a BIMS of four, indicating the resident had a severely impaired cognition. During an interview on 8/26/21 at 3:08 p.m., the Administrator stated that R#63 did not have a POA. During interview on 8/27/21 at 1:46 p.m., the Administrator stated the nurses should know the code status of a resident before admission, and it should be on the POLST form. The Administrator acknowledged the lack of appropriate signatures on the POLST forms.

Based on observation, interview, and policy review, the facility failed to ensure that appropriate personal protective equipment (PPE), including a mask and face shield, was utilized on two of three COVID-19 designated halls (D and E). Findings include: Observation on 8/12/20 at 9:50 a.m., revealed the of COVID 19 positive areas to be the D, E, and F hall (designated with signage on the closed fire door entrance to each hall). Observation of the E hall doorway at 12:29 p.m. on 8/12/20 showed the Therapy Director (TD) GG exited the hallway without a mask or face shield, removed gloves, and held the used gloves in her hand, while putting on a new clean gown. When asked about the PPE, TD GG confirmed she did not have a mask on. She then removed the gown and walked away. At 10:12 a.m. on 8/12/20, Environmental Services Worker (EVS) AA exited the D hall with a face mask, gown and gloves on carrying a bag of trash. In an interview on 8/12/20 at 10:24 a.m., the Director of Nursing (DON) observed EVS AA don PPE, go into Room D1, where she was cleaning. Upon observing EVS AA, through the fire door windows, the DON saw that EVS AA was not wearing a face shield. After talking with the DON, EVS AA returned to the housekeeping cart to retrieve her face shield. In an interview on 8/12/20 at 2:20 p.m., the DON confirmed the EVS personnel should wear goggles or face shields when working on the units where infectious residents resided. Review of the October 2010 revision of the facility policy titled, Personal Protective Equipment - Using Face Masks, indicated: .When to Use a Mask 1. When providing treatment or services to a patient who has a communicable respiratory infection; 2. When providing treatment or services to a patient and the use of a mask is indicated; and 3. When performing a task that may involve the splashing of blood or body fluids into the mouth or nose. Review of the policy revealed it was not updated to address using masks for protection from the [MEDICAL CONDITION].

Based on observations, interviews, and record reviews the facility failed to order PRN (as needed) [MEDICAL CONDITION] medications in the required manner of including a duration and/or a specific indication for five residents (R), (R# 25, R#57, R#80, R#99, and R#103). The sample size was 38 residents Findings include: 1. Review of the medical record revealed Resident # 57 had the [DIAGNOSES REDACTED]. Physician's progress note dated 8/9/18 to continue [MEDICATION NAME] as needed for sleep. Review of the Medication Administration Review revealed (MAR) revealed [MEDICATION NAME] was received in (MONTH) on the 2nd; received 6 times in (MONTH) on the 1st, 4th, 5th, 8th, 11th, and 20th; and received 3 times in (MONTH) on the 3rd, 4th, and 19th. During interview on 9/20/18 at 11:40 a.m. with Licensed Practical Nurse (LPN) Supervisor DD revealed that she was not aware of regulation changes related to as needed medications (PRN) related to duration of time for usage. LPN Supervisor DD reported that she has not questioned the doctor regarding the duration of PRN medications. 2. Review of the admission face sheet for R#103 reveals a primary [DIAGNOSES REDACTED]. Delusional disorders and anxiety disorder were added on 2/1/18. A review of Physician order [REDACTED]. The date of the record review is 9/19/18 which is 30 days later. A review of the Medication Record document for R#103 reveals no PRN [MEDICATION NAME] was given in the month of August, one dose was administered in July, and three doses were administered in June. A review of the Behavior/Intervention Monthly Flow Record reveals R#103 had no behaviors in August, no behaviors in July, and there is no documentation for the month of June. A review of the Social Progress Notes for R#103 dated 2/20/18, 3/9/18, 6/8/18, and 9/3/18 reveals no behaviors or anxiety. For the note in 6/8/18 the note indicates resident may have the delusion that her roommate got in her bed and that the resident across the hall is talking about her and taking her coffee off her tray. A review of a Consultant Pharmacist Communication to Physician document dated 1/16/2018 for R#103 reveals an order for [REDACTED]. The physician checks the box for clinically contraindicated and no duration is provided. The physician's signature is dated 1/2/18. A review of Consultant Pharmacist Communication to Physician document dated 3/29/2018 for R#103 reveals an order for [REDACTED]. The physician checks the box for indefinitely for chronic anxiety. The physician's signature is dated 4/11/18. 3. A review of Consultant Pharmacist Communication to Physician document dated 12/28/2017 for R#80 reveals an order for [REDACTED]. The physician checks the box for clinically contraindicated and no duration is provided. The physician's signature is dated 1/17/18. A review of Consultant Pharmacist Communication to Physician document dated 8/23/2018 for R#80 reveals an order for [REDACTED]. The physician checks the box for 90 days and no clinical indication is provided. The physician's signature is dated 9/14/18. 4. A review of Consultant Pharmacist Communication to Physician document dated 4/25/2018 for R#99 reveals an order for [REDACTED]. The physician records a note indicating a duration of 6 months. The document includes the option of indefinitely. The physician's signature is dated 5/16/18. Interview on 9/19/2018 at 12:05 p.m. with the Administrator regarding the order for PRN [MEDICATION NAME] for R#103 and the pharmacy language for indefinitely as a duration. She declines a response and calls the Pharmacist and he is placed on speaker phone to speak with the surveyor. The pharmacist reports he is familiar with the use of the word indefinite on the document and he reports the pharmacy would continue to do their monthly and quarterly reviews, and as needed, for the medication. He wants to call the pharmacy consultant for further input regarding the language on the form. Interview on on 9/19/2018 at 12:30 p.m. and review of the Consultant Pharmacist Communication to Physician with the Physician revealed that he reports he wrote the order because the resident was receiving hospice care. The Physician agreed that indefinite is not a duration. Phone interview on 9/19/18 at 1:45 p.m. with the facility pharmacy consultant revealed that there has been a problem getting Physicians to give a duration. He reports he is aware of the regulation requiring a duration for PRN [MEDICAL CONDITION] medications. He reports the duration is whatever the physician defines as a duration. Interview on 9/20/18 at 8:41 a.m. with LPN HH is not familiar with the the regulation requirements for a duration in an order for [REDACTED]. Interview on 9/20/18 at 8:41 a.m. with LPN II revealed that LPN II is not familiar with the regulation requirements for a duration in an order for [REDACTED]. 4. A review the admission face sheet for R#25 reveals an admission date of [DATE] and primary [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. A review of Medication Record document for R#25 reveals no PRN [MEDICATION NAME] was given in month of September, and one dose was administered in August. A review of Behavior/Intervention Monthly Flow Record reveals R#25 had no behaviors in (MONTH) and no behaviors in August. A review of Consultant Pharmacist Communication to Physician document dated 1/16/2018 for R#25 reveals an order for [REDACTED].>14 days in the resident's medical record. The physician checks the box for clinically contraindicated and no duration is provided. The physician's signature is dated 1/2/2018. A review of Consultant Pharmacist Communication to Physician document dated 3/29/2018 for R#25 reveals an order for [REDACTED]. The physician checks the box for indefinitely for chronic anxiety/agitation. The physician's signature is dated 4/11/2018. A review of Consultant Pharmacist Communication to Physician document dated 6/14/2018 for R#25 reveals an order for [REDACTED].>14 days in the resident's medical record. The physician checks the box for clinically contraindicated and no duration is provided. The physician's signature is dated 7/11/2018

Based on interview, observation, and review of policy's titled Food Storage and Food Safety for Your Loved One the facility failed to discard expired items, failed to label and date items upon delivery, and failed to indicate a use by date for items. This included dry storage area in the kitchen and two of two resident nourishment rooms. The census was 111 residents. Findings include: During the initial kitchen tour on [DATE] at 10:14 a.m. with the Certified Dietary Manager (CDM) revealed the following: 1. There was a container with prune juice thawed without a thaw or use by date. 2. There was bread in containers dated with [DATE], [DATE], and [DATE] but there was no expiration date for the bread. There were also two 12 count hamburger bun and five loaves of wheat bread without a use by date. 3. There were Soft and chewy cookies,(NAME)Brand Cheddar Cheese Crackers, and Cheeze It in a container labeled snacks but there was no way to determine the use by date. During second kitchen tour on [DATE] at 5:41 p.m the following was revealed: 1. In the second dry storage area there were 2 large plastic containers with single serve cereal bowls but there was no way to identify the expiration date for Rice Krispies and Raisin Bran Cereal. 2. In the large plastic containers with flour, cornmeal, and sugar each was without an in date or expiration date. During the tour of the Nourishment room on A Hall on [DATE] at 12:41 p.m. with DON revealed: 1. There were three containers of prune juice and one container of cranberry juice that did not have an expiration date. During the tour of Nourishment room on F Hall on [DATE] at 12:46 p.m. with Unit Manager, revealed: 1. There was one container of cranberry juice without a use by day and two Powerade Zero with an expiration date of [DATE]. During an interview on [DATE] at 10:29 a.m. with the CDM it revealed that bread arrives frozen and is thawed as needed. CDM acknowledged that there is no way to indicate when this bread is to be used by based on the current system used. During an interview on [DATE] at 5:25 p.m. with the CDM revealed that once bread is thawed it should be used in 7 days. CDM further reported that the Hamburger buns were delivered on last Friday for usage on Tuesday's lunch. However, the buns were not labeled. During an interview on [DATE] at 5:45 p.m. with the CDM revealed that she would contact the vendor for expiration dates of cereal, crackers, cookies, and other identified items. The CDM reported that she does not know how to read the code on the cereal to determine expiration dates. During an interview on [DATE] at 12:29 p.m. with the CDM regarding policy. CDM confirmed that bread and juices (orange juice, prune juice, and cranberry juice) did not have expiration dates and there was no labeling for bulk items (flour, sugar, corn meal) to indicate in date or use by date. During an interview with the DON on [DATE] at 12:41 p.m. it was reported that refrigerators in the nourishment rooms were last checked on Monday and that nursing is responsible for the upkeep of resident refrigerators. Food Storage Policy dated 2013 Refrigerated Food Storage: f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Resource: Food Safety for Your Loved One Food or beverages should be labeled and dated to monitor for food safety: 4. Food or beverage items without a manufacturer's expiration date should be dated upon arrival in the facility and thrown away three days after the date marked.

Based on observation, staff interview, and review of the facility policy titled Infection Control Guidelines for All Nursing Procedures the facility failed to ensure infection control practices were maintained to prevent the potential for infection and cross contamination for one resident (R) (R#409) in isolation for [MEDICAL CONDITION] (C diff) (an infectious disease causing severe diarrhea). The sample size was 38 residents. Findings include: Observation on [DATE] at 8:09 a.m. revealed a table in the hallway outside of R#409's room with gowns, masks, and gloves on it. Continued observation revealed that CNA EE and CNA FF (an employee in orientation with CNA EE) entered R#409's room without putting on a gown, mask, or gloves. CNA EE opened a cream packet and sugar packet and put it in R#409's coffee. Continued observation revealed that CNA EE opened the salt and pepper packets and sprinkled it on the food on R#409's breakfast tray. CNA EE then applied hand sanitizer on her hands and left the room. Interview at this time with CNA EE revealed that the disposable gowns, masks, and gloves on the table were because the resident had[DIAGNOSES REDACTED]. CNA EE stated that she thought that R#409 had[DIAGNOSES REDACTED] for about a week. Observation on [DATE] at 12:15 p.m. revealed that CNA EE and CNA FF entered R#409's room to turn off the call light. Further observation revealed that neither CNA put on a gown or gloves before entering the room. CNA EE turned off the call light and didn't wash her hands before leaving the room. Continued observation revealed a table in the hallway outside of R#409's room with gowns, masks, and gloves on it. Observation on [DATE] at 8:31a.m. revealed CNA EE at R#409's bedside feeding resident her breakfast. CNA EE didn't have on a gown or gloves. Further observation revealed a table in the hallway outside of the R#409's room with gowns, masks, and gloves on it. During an interview on [DATE] at 8:30 a.m. with Unit Manager (UM) CC revealed that R#409 had gowns, masks, and gloves outside her room because she was on contact precautions because she had[DIAGNOSES REDACTED]. Continued interview revealed that the resident had been diagnosed with [REDACTED]. During an interview on [DATE] at 8:33 a.m. with CNA EE revealed that she has been educated on transmission- based precautions (TBP). Continued interview revealed that she only wears a gown and gloves if she is going to come in contact with body fluids. During an interview on [DATE] at 9:25 a.m. with the Director of Nursing (DON) revealed that the facility does not have a policy on transmission-based precautions. During an interview on [DATE] at 10:05 a.m. interview with UM CC revealed that it is her expectation for staff to use precautions and not spread infections to other residents if a resident is on TBP. Stated that the most important thing is for staff to wash their hands with soap and water. Continued interview revealed that staff is not expected to wear a gown and gloves unless they're in direct contact with body fluids. Further interview revealed that she wouldn't expect staff to put on gown and/or gloves if they were entering the room of TBP if they were turning off a call light or assisting with feeding a resident. UM CC stated that she has not received any education on TBP at the facility in the last year. During an interview on [DATE] at 11:04 a.m. with the DON revealed that when a resident is on TBP the most important thing is for staff to wash their hands with soap and water instead of using hand sanitizer. Continued interview revealed that it is her expectation to staff to wear gown and/or gloves when they are about to provide care. Further interview revealed that it is her expectation for staff to wear a gown and gloves if they were feeding a resident on TBP. Review of R#409's medical record revealed a [DIAGNOSES REDACTED].>Review of facility policy titled Infection Control Guidelines for All Nursing Procedures revised (MONTH) 2012 revealed under Preparation #1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, including: a. The facility protocols for isolation (standard and transmission-based) precautions. #2. Transmission-Based Precautions will be used whenever measures more stringent that Standard Precautions are needed to prevent the spread of infection. g. When there is likely exposure to spores (i.e [DIAGNOSES REDACTED]icile or Bacillus anthracis). For effective mechanical removal of spores, wash hands for ,[DATE] seconds with soap and water or 2% [MEDICATION NAME].) #5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. Review of education inservice titled Substance Abuse, Infection Control, CPR, and Workplace Violence dated [DATE] revealed Lesson #4 [MEDICAL CONDITIONS]- bacteria which causes severe watery diarrhea and other intestinal disease when competing bacteria have been wiped out by antibiotics; It is spread by spores that are difficult to kill and can be carried on the hands of caregivers who have direct contact with residents or an environmental surface (i.e, floors, toilets, bedpans). Further review of attendance sign in sheet revealed that neither CNA EE, CNA FF or UM CC attended the in service.

Based on record review, staff interview and review of a written policy titled Catheter Care, Urinary, the facility failed to follow the care plan for a resident who is totally dependant on staff for catheter care for one resident (R) (R#25). In addition, the facility failed to follow their policy for catheter care. The sample size was 38 residents. Finding include: R#25 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#25 complained of pain and leakage. Review of the the care plan for R#25 revealed she was at risk for secondary complications related to having a Foley catheter in place, history of UTI, and requires total assistance with catheter care. Interview on 9/20/2018 at 11:00 a.m. with BB LPN revealed that R#25 did not have an order for [REDACTED]. She revealed they have not attempted a trial of bladder training with R#25. Interview on 9/20/2018 at 11:10 a.m. with the Director of Nursing (DON) revealed that the facility does not use any form of ADL sheet, care card or computer to document ADL care including catheter care. Her expectation is they do it daily during routine care and during bathing but could not verify catheter care was provided.

Based on observation, staff interviews, and review of facility policy titled Administering Medications the facility failed to ensure that medications were labeled with an open date on one of three medication (med) carts and the facility failed to ensure that expired medications were removed from one of two medication storage rooms. The facility census was 111 residents. Finding include: Observation on 9-19-18 at 5:18 p.m. during a random inspection of medication (med) storage room for A, B, and C Halls revealed one box of [MEDICATION NAME] 1.25 mg/3 milliliters (mL) nebulizer vials containing twenty-four (24) vials with the expiration date of 8-2018. The Assistant Director of Nursing (ADON) acknowledged that the medication was expired during the inspection. Observation on 9-19-18 at 5:20 p.m. during a random inspection of med cart on A Hall with LPN ZZ revealed one bottle of [MEDICATION NAME] R for one resident (R) #86 without an open date and one bottle of stock [MEDICATION NAME] HCI without an open date. Interview on 9-20-18 at 9:41 a.m. with the Director of Nursing (DON) revealed that it is her expectation that an open date be marked on insulin once it is opened. Continued interview revealed that it is her expectation that expired medications be removed from medication carts, medication storage rooms and medication storage refrigerators for destruction during weekly audits. Further interview revealed that the facility does not use audit forms when checking for expired medications. Review of facility policy titled Administering Medications revised (MONTH) 2012, revealed the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.

Based on record review, staff interview and review of a written policy titled Catheter Care, Urinary, the facility failed to provide catheter care for one resident (R) (R#25). In addition. Finding include: Record review revealed that R#25 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the care plan for R#25 revealed she was at risk for secondary complications related to having a Foley catheter in place, history of UTI, and requires total assistance with catheter care. Interview on 9/20/2018 at 11:00 a.m. with BB LPN revealed resident did not have an order for [REDACTED]. She revealed they have not attempted a trial of bladder training with R#25. Interview on 9/20/2018 at 11:10 a.m. with the Director of Nursing (DON) revealed that the facility does not use any form of ADL sheet, care card or computer to document ADL care including catheter care. Her expectation is they do it daily during routine care and during bathing but could not verify catheter care was given. Review of the policy titled Catheter Care, Urinary revised (MONTH) 2014 revealed the following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine 5. Any problems noted at the catheter-urethral junction during perineal care. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 8. If resident refuses procedure and reason. 9. The signature and title of the person recording the data.

Based on observation and interviews the facility failed to ensure sanitary conditions related to cleanliness of one standup and one swing lift (dust, dirt, and buildup), failed to ensure one toilet was secure on the D hall, failed to ensure one wheelchair was in good repair for one resident (R#33), and failed to ensure the upkeep of resident furniture for one resident (R#5). This practice effected two of six halls. Findings include: Observation on 9/17/18 at 3:56 p.m. in room D4 there was missing tile from the floor in the bathroom, loose tile behind toilet, and further observation revealed that the toilet was loose. Observation on 9/17/18 at 4:22 p.m. in room D8 revealed that there was a loose base board under the dresser and dust buildup in the bathroom vent. Observation on 9/18/18 at 9:38 a.m. made of R# 5's bed revealed a large very sharp pointed piece of the foot board protruding from the bed, on the outside of the bed away from the resident. Observation on 9/19/18 at 9:17 a.m. of R#33 sitting in high back wheel chair that has rust on tippers and broken backing. Observation on 9/19/18 at 1:52 p.m. revealed that there was one stand up lift on the D hall noted to have white build up on base and neck of the lift and one swing lift on D hall noted to have white build up on base. During an interview on 9/18/18 at 9:38 a.m. with the Maintenance Supervisor he revealed that he was not informed of the broken bed for R#5. He stated if something is broken the staff are to fill out a maintenance request. Review of the maintenance request book revealed that there was no evidence that a maintenance request had been completed fo the broken bed. During environmental round with the Maintenance Supervisor on 9/20/18 from 11:55 a.m. until 12:20 p.m. revealed that Maintenance should be cleaning lifts when the lifts are serviced monthly but confirmed the build up on lifts in the hallway. It was further reported that a new wheelchair had been ordered for R#33 but there was no documentation to support that the chair had been ordered. Maintenance Supervisor reported that he had not been made aware of the loose toilet for D4 but would follow up to resolve the issue. The Maintenance Supervisor further revealed that he relies on nursing staff to let him know if there are areas that need to be repaired. He reported that the building is toured daily and an environmental check is done monthly. He stated that as issues are identified maintenance follows up to fix.

Based on medical record review and staff interviews, the facility failed to ensure the residents' plan of care was reviewed, updated and revised related to the falls for one (1) resident out of a sample of five (5) residents reviewed for falls. The sample size for this survey was 25 residents out of a census of 126. Findings include: Resident #13 (R#13) was found to have had 14 falls in the time frame between December 16, 2016 and October 16, 2017. There was no information about those falls placed in the residents' care plan for the following falls: 1. Resident #13 (R#13) fell on [DATE]. There was no update/revision to the care plan for this fall. 2. R#13 fell on [DATE]. There was no update/revision to the care plan for this fall. 3. R#13 fell on [DATE]. There was no update/revision to the care plan for this fall. 4. R#13 fell on [DATE]. There was no update/revision to the care plan for this fall. 5. R#13 fell on [DATE]. There was no update/revision to the care plan for this fall. During an interview with the Assistant Director of Nursing (ADON) on October 25, 2017 at 11:42 a.m. the ADON stated that she expects the care plan to be updated/revised by the nurse on the hall and the Resident Care Coordinator (RCC) each time there is a fall. She also stated the RCC is ultimately responsible for ensuring this information is placed on the residents' care plan. During an interview with Minimum Data Set (MDS) Coordinator (AA) on October 25, 2017 at 2:12 p.m. she stated that the nurses on the hall were responsible to place new interventions on the care plan for each fall, then flag the chart for the RCC to ensure the information about each fall and a new intervention was actually placed on the residents' care plan.

Based on medical record review, staff interviews and review of the facility's Accidents/Incidents policy, the facility failed to ensure immediate consultation with the residents' physician or to notify the residents' representative, consistent with her or her authority, when there was an accident involving one (1) resident out of a sample of five (5) residents reviewed for falls, which could have resulted in the potential for requiring physician intervention. The sample size for this survey was 25 residents out of a census of 126. Findings include: Resident #13 was found to have had 14 falls in the time frame between December 16, 2016 and October 16, 2017 and the following information was revealed: 1. Resident #13 (R#13) fell out of his bed on January 17, 2017. There was no notification of this fall to the physician or the residents' representative. 2. R#13 was found sitting on the floor in front of his wheelchair in his room on January 12, 2017. There was no notification of this fall to the physician or the residents' representative. 3. R#13 was found sitting in front of his wheelchair on the floor on one of the halls on March 5, 2017. There was no notification of this fall to the physician. 4. R#13 was found on the floor of his bathroom on March 8, 2017. There was no notification of this fall to the the residents' representative. 5. R#13 was found in his room on the floor on March 30, 2017. There was no notification of this fall to the residents' representative. 6. R#13 was found in his room on the floor on June 17, 2017. There was no notification of this fall to the residents' representative. There was no follow-up charting in the medical documentation monitoring the resident for this fall 7. R#13 was found lying on the floor in his room on his back on October 2, 2017. There was no notification of this fall to the residents' representative. On October 25, 2017 at 11:42 a.m. during an interview with the Assistant Director of Nursing (ADON), she stated because of the number of falls in the bathroom, he should have been evaluated and/or on the toileting program. During an interview with the Assistant Director of Nursing (ADON) on October 25, 2017 at 11:42 a.m. she stated that she expects the physician and the family to be notified of every incident or fall concerning their family member.

Based on record review, review of the facility's Grievances, Abuse Policy and Procedure and family and staff interviews, the facility failed to ensure that an allegation of abuse was thoroughly investigated and reported to the Administrator and State Agency (SA) for one resident (R) (R#1) of three residents reviewed for facility investigations of allegations of abuse. Findings include: Review of the facility Grievances, Abuse Policy and Procedures (n.d.) revealed that any person hearing a complaint of abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation must immediately report it to the Administrator, the Social Service Director, the Director of Nursing, and any other department head or nurse in charge. It will be the responsibility of any department head receiving the complaint of alleged abuse, corporate punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation to inform the administrator or designee immediately. A. Review of the facility Reporting of Incidents Policy (n.d.) revealed that once a complaint or situation is identified involving alleged mistreatment, neglect or abuse, the incident will be immediately reported. 1. The Administrator or designee will immediately notify the Complaint Investigation Intake and Referral Unit and the legal representative and/or interested family member of the incident and the pending investigation. The Administrator or designee will direct the investigation. 2. The initial report of incident will be telephoned or faxed in within 24 hours of the incident to the Complaint Intake and Referral Unit. Prior to calling in the incident, the Center Complaint Report Fax Form will be completed. B. A written report of the investigation will be reported to the administrator and the Long Term Care section Complaint Coordinator within five (5) working days of the incident. The investigation includes an interview conducted with all parties. Written signed statements from any and all parties will be obtained if possible. Statements will be gathered from the suspect, person making accusations, patient involved, reliable patients who may have witnessed the incident, and any other persons who may have information. Review of the Quarterly Minimum Date Set (MDS) for Resident (R#1), dated 3/29/17 identified the resident with a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. R#1 is totally dependent on staff and requires assistance for all Activities of Daily Living (ADLs) Review of current care plans in place revealed R#1 has behaviors that include; resistance to ADL care at times by refusing showers and refusing to get out of bed, easily annoyed with staff and at care received. She is noted with forgetfulness, has a history of depression and her mental function varies. Her current [DIAGNOSES REDACTED]. Resident (#1) was not responsive to surveyor attempts in interview during the investigation. Interview with the Resident #1's Family Member on 5/22/17 at 3:17 p.m. revealed that a couple of weeks ago, she informed Registered Nurse (RN) AA that R#1 said that she had been slapped, hit and yelled at by Certified Nursing Assistant (CNA) BB. The family member revealed R#1 said BB had been hollering at her, slapped her, and told R#1 she was going to bathe her even though R#1 did not want the bath. R#1 additionally informed the family member, CNA BB pulled her covers up and hit her underneath the cover. The family member denied seeing any marks on R#1 and does not know when the incident occurred but added, she spoke with RN AA about the incident the next day and was told CNA BB would not be allowed back in R#1's room. The family member is not sure if the CNA ever returned to R#1's room. The family member revealed she expected the nurse to take care of the complaint but she does not believe it was ever investigated. Review of facility grievance logs, and State reportable incidents February 2017 to current date revealed no grievance report, incident report, progress notes or investigation regarding R#1. Interview with RN AA on 5/18/17 at 10:22 a.m. revealed R#1's family member told her that R#1 said CNA BB was rough with her in the shower but R#1 does not go into the shower. RN AA further revealed she told CNA BB not to go into R#1's room anymore and CNA BB has not entered the room since. When asked about why she did not report or investigate the incident, RN AA added, at the time, I did not see it as an incident or allegation , we have alot of people with behaviors here. I should have written up every allegation and reported it to the family and the doctor. If a patient says someone has abused them or if you see it, you should report it to the immediate supervisor. That is our process and I have been in-serviced on that. Interview with CNA BB on 5/18/17 at 3:09 p.m. revealed she was not aware of what the allegation was against her. CNA BB: further revealed she is on the bath team and has provided bathing care for R#1; however, she made sure that she had a co-worker with her the last few times she bathed R#1 because R#1 is difficult to bathe because of her size. CNA BB also revealed she was not aware of any allegation from the resident about her hitting or cursing her and after she was told that R#1 said something about her, RN AA told her it would be best if she did not provide care for R#1 anymore and CNA BB did not provide care for R#1 again after that incident. CNA revealed she has received in-service training on the abuse reporting process. Interview with the Director of Nursing (DON) on 5/18/17 at 1:24 p.m. revealed that she would expect the nurse in charge to notify her of any abuse investigation so she could investigate. The DON also revealed the RN AA should have notified the physician and family of any allegation of a resident being roughed up and there should have been an assessment. The accused would have been suspended until staff determined she didn't do anything. Interview with the facility Administrator on 5/18/17 at 8:35 p.m. revealed, that her expectation is that the policy is followed, then staff can investigate and let the proper people determine if an allegation is true or not. The allegation should have gone through the investigation process. The Administrator agreed the reporting process was not done per the facility policy.

Based on observations and interviews, the facility failed to ensure that foods were stored in a safe and sanitary manner in two (2) of two (2) food pantry refrigerators and freezers. One (1) pantry for A, B, C and one (1) pantry for D, E, and F. Findings include: Food Pantry for Halls A, B, and C During observations of the food pantry on 05/25/2016 at 8:19:09 a.m. and at 2:29 p.m. the following items were observed: One (1) sixty four (64) ounce (oz.) container of 100 percent prune juice with a best by date of 5/15/15, one (1) opened twelve (12) oz. can of Mellow Yellow not labeled or dated, one (1) opened 8 oz. container of milk not labeled or dated, three (3) containers of expired yogurt, and one (1) cup containing ice not labeled or dated. There was also a black substance pooled at the bottom of the refrigerator and freezer portion of the refrigerator did not have a thermometer. The freezer also contained one (1) container of vanilla ice cream that was soft to touch. During an interview and observation on 5/25/16 at 4:55 p.m. with the Director of Nursing (DON) he/she confirmed the following items in the resident refrigerator: expired items include prune juice (5/1/15), peach yogurt (2/8/16), key lime yogurt (2/1/16); twelve (12) oz. can of Mellow Yellow that was opened, not dated or labeled; one (1) opened 8 oz. container of milk not labeled or dated; and soft ice cream in the freezer. The DON also confirmed a black substance pooled in the bottom of the refrigerator and rust on the inside door of the microwave. The DON stated that housekeeping staff are responsible for cleaning the microwave. The DON stated that the facility had not been keeping a temperature log of the freezer section of the resident refrigerator. The DON stated it was the night nurse's responsibility to check temperatures, expiration dates, and keep the resident refrigerator clean. Food Pantry for Halls D, E and F First observation of the food pantry on 05/25/2016 at 10:21 a.m., revealed the resident refrigerator did not have a thermometer and there was one (1) Imperial Thickened Dairy Drink with expiration date of 4/29/16. In the freezer there was one (1) twelve (12) oz. can of Dr. Pepper and one (1) vanilla pudding container with no name. There also was no thermometer in the freezer. During an interview and observation on 5/25/16 at 5:07 p.m., with the DON, he/she confirmed the following: there was not a thermometer in the refrigerator, there was one (1) container of Imperial Thickened Dairy Drink with an expiration date of 4/29/16. In addition, in the freezer section there was one (1) unlabeled can of Dr. Pepper, one (1) unlabeled vanilla pudding container, and no thermometer. An interview on 5/25/16 at 5:09 p.m. with LPN Supervisor JJ who stated that there had only been one thermometer in D, E, and F halls food pantry refrigerator since a new refrigerator was added. LPN JJ further stated that one thermometer had been used between the resident refrigerator and the staff refrigerator to obtain temperatures. LPN Supervisor JJ provided copies of the temperature log for resident refrigerator in D, E, and F halls pantry and there was no log available for freezer temperatures. A follow up interview on 5/25/16 at 5:11 p.m. with the DON who stated that the expectation was for all refrigerators to have their own thermometer and that staff should have notified the DON that there was only one thermometer.

Based on record review and staff interview, it was determined that the facility failed to provide care in accordance with the Care Plan for one (1) resident (#89), related to fall-prevention, and for one (1) resident (#165), related to monitoring of the [MEDICAL TREATMENT] access, from a total survey sample of thirty (30) residents. This failure resulted in actual harm for Resident #89, who sustained multiple falls, one of which resulted in a hematoma to the resident's forehead and bruising to the right wrist. Findings include: 1. Record review for Resident #89 revealed an Admission Minimum Data Set (MDS) assessment of 05/23/2013 documenting diagnoses, in Section I - Active Diagnoses, which included [MEDICAL CONDITIONS], Hypertension, Diabetes Mellitus, Arthritis, [MEDICAL CONDITION] Disorder and Dementia. Section J - Health Conditions documented a history of falls since admission. A Care Plan entry of 05/28/2013 for Resident #89 identified the resident's risk for falls. This Care Plan identified multiple Approaches to address Resident #89's fall-risk, with one of the Approaches specifying that the facility assess the cause and the pattern of previous falls, and act upon resolvable factors. Further record review for Resident #89 revealed Nurse's Notes entries of 11/10/2013 at 8:00 p.m., 11/18/2013 at 8:45 p.m., and 11/26/2013 at 5:00 p.m., each documenting that the resident had fallen to the fall mat beside the bed. The 11/18/2013, 8:45 p.m. Nurse's Notes entry documented that Resident #89 was noted to have a hematoma on the forehead and bruising to the right wrist. However, despite the Care Plan for Resident #89 specifying that staff assess the cause and the pattern of falls and act upon resolvable factors, record review revealed no evidence to indicate that after the falls of 11/10/2013, 11/18/2013, and 11/26/2013 referenced above, facility staff reassessed and reevaluated the resident, as specified by the Care Plan, in an attempt to analyze the cause of the continued falls and to evaluate the pattern of these falls, to allow for the identification of any resolvable factors related to the falls. During an interview conducted on 12/05/2013 at 2:35 p.m., Resident Care Coordinator (RCC) "CC" was questioned regarding Resident #89's continued falls, and acknowledged the above. Cross refer to F323 for more information regarding Resident #89. 2. Record review for Resident #165 revealed an Admission MDS of 10/14/2013 which documented in Section I - Active [DIAGNOSES REDACTED]. Section O - Special Treatments and Programs of this MDS also indicated that Resident #165 received [MEDICAL TREATMENT]. Review of Resident #165's Care Plan revealed an entry of 10/14/2013 which identified that the resident had a [DIAGNOSES REDACTED]. An Approach on Resident #165's Care Plan related to the resident's [MEDICAL TREATMENT] therapy specified that nursing staff assess for the presence of bruit and thrill every shift, and as needed, and notify the physician in the absence of bruit and thrill. However, review of Resident #165's clinical record revealed no evidence to indicate that nursing staff had assessed the resident's [MEDICAL TREATMENT] for thrill and bruit. During an interview with Nurse "BB" conducted on 12/05/2013 at 10:35 a.m., this nurse acknowledged that staff did not check the resident's access site for thrill and bruit. Cross refer to F309 for more information regarding Resident #165.

Based on record review and staff interview, it was determined that the facility failed to assess and address the root cause of falls and implement new interventions to prevent further falls for one (1) resident (#89), who had a history of [REDACTED]. This failure resulted in actual harm for Resident #89, who sustained multiple falls, one of which resulted in a hematoma to the resident's forehead and bruising to the right wrist. Findings include: Record review for Resident #89 revealed an Admission Minimum Data Set assessment with and Assessment Referenced Date of 05/23/2013 which documented an Entry Date of 05/14/2013, and documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident #89 had a Brief Interview for Mental Status (BIMS) summary score of 03, indicating that the resident had severe cognitive impairment. Section G - Functional Status documented that the resident was totally dependent on staff for transfers and was not steady for surface-to-surface transfers, and Section J - Health Conditions documented that Resident #89 had fallen since facility admission. A Nurse's Notes entry of 10/13/2013 at 7:30 p.m. for Resident #89 documented that the resident was observed on the floor mat by the bed, and that the resident had no complaint of pain. A Nurse's Notes entry of 10/13/2013 at 7:35 p.m. documented that nursing staff assessed Resident #89 for injuries, to include obtaining vital signs and determining that the resident could move all extremities. A Nurse's Notes entry of 10/15/2013 at 2:30 p.m. for Resident #89 documented that a pressurized alarm had been applied to the resident's bed after the fall of 10/13/2013. A Nurse's Notes entry of 11/10/2013 at 8:00 p.m. for Resident #89 documented that the resident was again found to have fallen onto the fall mat beside the bed. This Nurse's Notes entry also documented that the nurse practitioner was notified of the fall. No injury was noted. However, further record review revealed no evidence to indicate that Resident #89 was evaluated after this fall of 11/10/2013 to assess the potential cause(s) of the fall and to determine the need for modification of, or addition to, the existing methods of fall-prevention being utilized for the resident, to ensure the resident's safety. A Nurse's Notes entry of 11/18/2013 at 8:45 p.m. for Resident #89 then documented that the resident was observed to be laying face down on the fall mat beside the bed. This Nurse's Notes entry documented that a hematoma was noted to Resident #89's forehead, and that bruising was noted to the right wrist. The entry further documented that the nurse practitioner was notified of the fall, and that the resident's status was assessed, to include vital signs. However, even after Resident #89's fall with injury, as documented in the 11/18/2013, 8:45 p.m. Nurse's Notes entry referenced above, there was no evidence to indicate that nursing staff evaluated the resident after this fall to assess the potential cause(s) of the fall and to determine the need for modification of, or addition to, the existing methods of fall-prevention being utilized to address the resident's falls. A subsequent Nurse's Notes entry of 11/26/2013 at 5:00 p.m. documented that Resident #89 was again observed to have fallen to the floor mat beside the bed, and was sitting on the mat with his/her back against the bed. Assessment at that time revealed no evidence of any injury. However, even after this fall, there was no evidence of evaluation of the potential cause(s) of the fall or to determine the need to modify the methods of fall-prevention being utilized. During an interview conducted on 12/05/2013 at 2:35 p.m., Resident Care Coordinator (RCC) "CC" was questioned regarding Resident #89's continued falls. RCC "CC" stated that in the evenings, after 3:00 p.m., Resident #89 was noted to begin looking for family members, which was what the resident was doing when attempting to get out of bed during each of the falls of 11/10/2013, 11/18/2013, and 11/26/2013. RCC "CC" acknowledged that no new interventions or actions had been developed related to Resident #89's falls in November 2013. Based on the above, despite Resident #89 having a history of falls with prior interventions to address this fall-risk, the resident sustained [REDACTED]. The resident then sustained a subsequent fall from bed on 11/18/2013 resulting in a hematoma to the forehead and a bruised wrist. However, after this 11/18/2013 fall, the facility failed to put additional interventions in place to address the resident's continued falls. The resident then fell , again from the bed, on 11/26/2013, but the facility still failed to evaluate the resident to determine the need for additional interventions to address continued falls.