Every finding on record at Eastgate Manor Nursing and Rehabilitation

Based on observation and interview, the facility failed to ensure an environment that was safe, sanitary, and comfortable for 6 of 18 rooms observed. Walls were damaged, lights were not functional, light pull cords were not functional, and privacy curtains were not clean. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: 1. On 4/15/24 at 11:31 a.m., room [ROOM NUMBER] was observed. The bathroom walls were observed to be scratched and gouged. 2. On 4/15/24 at 2:06 p.m., room [ROOM NUMBER] was observed. The light closest to the entry door was observed to not work and the privacy curtain was observed to be stained with a dry brown substance. 3. On 4/15/24 at 2:16 p.m., room [ROOM NUMBER] was observed. The bathroom walls were observed to be scratched and gouged. 4. On 4/15/24 at 2:20 p.m., room [ROOM NUMBER] was observed. Two hooks were observed protruding from the wall above the bed and multiple screws and nails were observed protruding from the entry door wall. 5. On 4/16/24 at 2:08 p.m., room [ROOM NUMBER] was observed. The light above the bed was observed to be missing a pull cord. 6. On 4/16/24 at 2:09 p.m., room [ROOM NUMBER] was observed. The pull cord above the bed was observed to be too short to be accessible for the resident. During an interview on 4/19/24 at 12:45 p.m., the Executive Director indicated the wall damage, light pull cords, and privacy curtain were in need of repair and cleaning. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set assessment for 2 of 18 residents reviewed. A urinary catheter and discharge was coded inaccurately. (Resident 52, Resident 54) Findings include: 1. Resident 52's clinical record was reviewed on 4/17/24 at 11:55 a.m. The diagnoses included, but were not limited to, obstructive and reflux uropathy, unspecified, and neuromuscular dysfunction of bladder. Physician orders, dated 4/1/24 through 4/19/24, for Resident 52 indicated . cath [catheter] orders: Foley catheter Size: 18 Fr [french] 10 mL [milliliters] bulb . The start date for the Foley catheter was 3/26/24. Resident 52's Admission Minimum Data Set (MDS) assessment, dated 3/31/24, indicated the resident did not have a Foley catheter during the 7 day look back period of 3/25/24 through 3/31/24. 2. Resident 54's clinical record was reviewed on 4/17/24 at 11:56 a.m. The diagnosis included, but was not limited to, sepsis. Nursing Progress Notes, dated 1/6/24 at 9:56 a.m., for Resident 54 indicated, Estimated discharge date : 2/6/24. Planned discharge location: home with home care and family support. Nursing Progress Notes, dated 1/17/24 at 9:36 a.m., for Resident 54 indicated, Estimated discharge date : 2/16/24. Planned discharge location: home with family support. Nursing Progress Notes, dated 1/24/24 at 12:23 p.m., for Resident 54 indicated, Estimated discharge date : 2/16/24. Planned discharge location: home with family support. Resident 54's Discharge MDS assessment, dated 2/5/24, indicated the resident went home to the community and the discharge was not planned. During an interview on 4/18/24 at 11:29 a.m., the Executive Director indicated the MDS's for Resident 52 not having a Foley catheter and for Resident 54's discharge not being planned were coded incorrectly. On 4/19/24 at 12:19 p.m., the Executive Director provided the facility's policy,Resident Assessment (RAI) Medicare MDS Scheduling with a reviewed date of 4/2023, and indicated it was the policy currently being used by the facility. A review of the policy did not indicate ensuring accurate coding of the MDS. 3.1-31(d)

Based on interview and record review, the facility failed to ensure a care plan meeting was held in conjunction with the Quarterly Minimum Data Set (MDS) assessment for 1 of 2 residents reviewed for care planning. (Resident 49) Findings include: During an interview on 4/16/24 at 11:40 a.m., Resident 49 indicated he and his wife had not been invited to a care plan meeting for a long time and he had not been kept informed of what was going on with his plan of care or when he was going to be able to be discharged back home. Resident 49's clinical record was reviewed on 4/17/24 at 11:00 a.m. The diagnoses included, but were not limited to, incomplete lesion at C5 level of cervical spinal cord and quadriplegia. A review on 4/17/24 at 11:15 a.m., of the Care Conference Summary notes indicated Resident 49 and his wife attended a care conference meeting on 1/3/24. A care plan, initiated on 3/22/24, and current through target date 6/22/2024, for Resident 49 indicated, . PROBLEM: Resident's discharge goal is to return to the community. Home with possible home care . GOAL: Resident will be discharged to return home with family support and possible home care . APPROACH: Resident and resident representative will be encouraged to participate in the discharge planning process . Resident 49's Quarterly MDS assessment was dated 3/20/24. The clinical record lacked documentation of a care plan meeting being held during that time. During an interview on 4/19/24 at 10:54 a.m., the Social Worker indicated Resident 49 was almost a month overdue for his care plan meeting. The meeting should have been held during the time the most recent MDS assessment was completed on 3/20/24. On 4/19/24 at 1:07 p.m., the Executive Director provided the facility's policy,IDT Care Plan Review Guidelines with a reviewed date of 8/2023, and indicated it was the policy currently being used by the facility. A review of the policy did not indicate how often a care plan meeting should be held. 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to ensure staff assisted a resident in gaining access to vision services by making appointments for 1 of 1 resident reviewed for ancillary services. (Resident 14) Finding includes: During an interview on 4/15/24 at 2:22 p.m., Resident 14 indicated her eyes were getting worse and she thought she needed new glasses. She indicated she had an eye doctor she was supposed to go see, however, she did not know when her next appointment was scheduled. On 4/16/24 at 11:12 a.m., Resident 14's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes type 2 and hypertension. A 2/7/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A 8/29/23 Optometry Doctor (OD) assessment, indicated the patient was diagnosed with diabetic retinopathy (damage to the blood vessels in the tissue at the back of the eye), macular degeneration (loss in the center of the field of vision), pseudophakia (having an artificial lens implanted after the natural eye lens has been removed), dry eye, and presbyopia (when your eyes gradually lose the ability to see things clearly up close). The eye doctor referred the resident to be see by a retinal specialist for diabetic changes in her eyes and reduced vision. A 4/19/21 Request for Service Consent, indicated the resident requested services for eye care. An 11/13/23 Social Services Assessment, indicated the resident needed ancillary referrals for vision. During an interview on 4/19/24 at 12:33 p.m., the Executive Director (ED) indicated the Social Services Director would be responsible for setting up OD referrals after the appointment. During an interview on 4/19/24 at 12:58 p.m., the ED indicated staff talked to the resident about getting seen outside of facility for services and she refused. She indicated there were no notes which indicated the resident refused to be seen related to the OD's referral to the retinal specialist. On 4/19/24 at 1:30 p.m., the ED provided the facility policy, Vision and Hearing Services, revised on January, 2006, and indicated it was the policy currently being used. A review of the policy indicated, . All resident requiring vision . services outside the facility will be assisted with the necessary arrangements . 3.1-39(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a urinary drainage bag and tubing attached to a urinary catheter was positioned off the floor for 1 of 1 resident reviewed for urinary catheters. (Resident 52) Finding includes: On 4/15/24 at 10:54 a.m., Resident 52 was observed to be sitting in her wheelchair in her room. The urinary drainage bag was observed to be touching the floor. On 4/15/24 at 3:08 p.m., Resident 52 was observed to be rolling around the hallway in her wheelchair. The urinary drainage bag was observed to be dragging the floor. On 4/17/24 at 11:10 a.m., Resident 52 was observed to be sitting in her wheelchair in her room. The urinary drainage tubing was observed to be been touching the floor. Resident 52's clinical record was reviewed on 4/17/24 at 11:55 a.m. The diagnoses included, but were not limited to, obstructive and reflux uropathy, unspecified, and neuromuscular dysfunction of bladder. Physician orders, dated 4/1/24 through 4/19/24, for Resident 52 indicated . cath [catheter] orders: Foley catheter Size: 18 Fr [french] 10 mL [milliliters] bulb . Nursing Progress Notes, dated 3/31/24, indicated Resident 52 was being treated for a urinary tract infection. A care plan, initiated on 3/26/24, and current through target date 6/26/24, for Resident 52 indicated, . PROBLEM: Resident requires an indwelling urinary catheter . GOAL: Resident will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection . APPROACH: Do not allow tubing or any part of the drainage system to touch the floor . On 4/18/24 at 11:06 a.m., Resident 52 was observed to be sitting in her wheelchair in her room. The urinary drainage bag and tubing was observed to be touching the floor. On 4/19/24 at 11:36 a.m., Resident 52 was observed to be sitting in her wheelchair in her room. The urinary drainage bag and tubing was observed to be touching the floor. During an interview on 4/19/24 at 11:37 a.m., Certified Nursing Assistant (CNA) 1 indicated the urinary drainage bag and tubing for Resident 52 was currently on the floor and should not be. On 4/19/24 at 12:19 p.m., the Executive Director provided the facility's policy,Nursing with a reviewed date of 6/2023, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 2. Resident Care Equipment . b. Urinary catheters should have a catheter bag cover over them or a wash basin underneath them as a barrier to prevent catheter bad or tubing from touching the ground . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety during 2 of 2 kitchen observations. Food packages were stored on the floor of the walk-in refrigerator and walk-in freezer, and food was open to air in the walk-in freezer. Finding includes: During an observation on 2/28/24 at 10:35 A.M. a walk-in freezer contained a bag of peas that were open to air. A walk-in refrigerator contained a box of chopped celery and a box of whole tomatoes resting directly on the floor. During an observation on 2/29/24 at 9:55 A.M., a walk-in freezer contained a bag of peas that were open to air and a box of meat patties resting directly on the floor. A walk-in refrigerator contained a box of chopped celery and a box of whole tomatoes resting directly on the floor. During an interview on 2/29/24 at 10:00 A.M., Cook 2 indicated that stored food containers should be wrapped up or closed tightly to ensure the food is not open to air and that food containers should be stored up off of the floor. On 2/29/24 at 11:35 A.M., the facility administrator supplied a facility policy titled, Food Storage and dated, 10/2017. The policy included, Policy . The Dietary supply storeroom is the center of control by maintaining the quality of products . Procedure . 10. Food is stored a minimum of 6 (inches) above the floor . on clean racks or other clean surfaces . 15. Frozen Foods: .d. Food should be covered or wrapped tightly . This citation relates to Complaint IN00427463. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and a homelike environment in resident spaces in 1 of 4 halls observed. (South hall) Findings include: 1. On 07/12/22 at 10:20 A.M., 2 (two) rolls of toilet paper were uncovered and sitting on top of the toilet tank in the bathroom of room 135. On 07/13/22 at 11:38 A.M., the same was observed. 2. On 7/11/22 at 11:10 A.M., the call light in the bathroom of room 139 was detached from the wall and hanging with wires out and the call light was not working. The sink was slow to drain. On 07/13/22 02:49 P.M., the same was observed. 3. On 07/11/22 at 10:51 A.M., there was a used washrag laying on an uncovered dishpan on the floor of the bathroom in the room of 136 observed. 1 (one) roll of toilet paper was uncovered and sitting on top of the toilet tank. A set of uncovered tongs was laying on the floor by the toilet and the sink was slow to drain. On 07/13/22 at 02:18 P.M., 2 (two) rolls of toilet paper were uncovered and sitting on top of the toilet tank. The tongs were still observed uncovered on the floor and the sink was still slow to drain. During an interview with the DON (Director of Nursing) on 7/14/22 at 10:50 A.M., she indicated the tongs were used as a therapy tool at one time. 4. On 07/11/22 at 10:47 A.M., used paper towels were observed on the bathroom floor of room 130. There was an uncovered urinal on the bathroom floor and the bathroom had a strong odor of urine. The sink was slow to drain. The vent on the bathroom ceiling was observed with open drywall around half of the vent cover which was not positioned correctly. It also had a layer of dust on it. Brown food debris was observed by the bed with ants around it. On 07/13/22 at 11:35 A.M., the sink was still slow to drain and the vent was not positioned correctly. During an interview on 07/14/22 10:54 A.M., Staff 2 indicated the toilet paper rolls used to come individually covered and now they do not come that way. She indicated they are supposed to put the uncovered rolls of toilet paper in a clean trash bags when carrying them to the resident rooms, then put them on the back of the toilets, uncovered. She also indicated staff was supposed to put uncovered items in the bathroom in trash bags when found. She indicated that they were supposed to look at vents in the bathrooms and clean as needed. During an interview on 07/14/22 at 10:56 A.M., the Regional Maintenance Staff, indicated he was unaware of the sinks draining slow in resident rooms. He indicated the call lights were checked monthly, and the last check was 2 (two) weeks ago. He was unaware of the call light being out of the wall in the bathroom of room 139. On 7/14/22 at 10:56 A.M., a maintenance policy was requested. The Regional Maintenance Staff indicated there was no policy for maintenance but staff used work orders for as needed fixes and a computer system for regular scheduled maintenance tasks. Staff were supposed to fill out a work order when they saw something that needed to be fixed and bring this to maintenance. He indicated the maintenance department had been short staffed recently and he was currently in this building 2 (two) to 3 (three) days a week. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure food items were properly labeled and not expired. There was food in the freezer open to air. The wall by the oven hood was peeled off, parts of the wall were hanging, brick was exposed, and debris was on the floor under the oven which included parts of the wall during 4 of 4 kitchen observations. Findings include: During the initial tour of the kitchen on [DATE] at 10:03 A.M., the following was observed: Dry storage: An open bag of devils food cake mix wrapped in plastic wrap dated [DATE] and [DATE]. An open bag of cheese sauce wrapped in plastic wrap dated [DATE], [DATE], [DATE]. A large container with oats dated [DATE] and [DATE]. An open vanilla instant pudding wrapped in plastic wrap dated [DATE]. An open chocolate pudding dated [DATE] and [DATE]. Plastic wrapped around aluminum foil with white crumbs dispersed throughout dated [DATE], [DATE], and two other unreadable dates. Refrigerator: A quart of half and half milk with the cap dated [DATE] and [DATE]. Freezer: A clear bag of homestyle chicken tenderloin in a bag sitting in a cardboard box was open to air, dated [DATE]. The wall on the left of the oven hood was peeling back with parts of the wall hanging, and wall debris was on the floor under the oven. At that time, Cook 6 indicated the devils food cake, cheese sauce, vanilla instant pudding, chocolate pudding, and half and half milk was expired and threw the items in the trash can. Cook 6 indicated that the label on the oats was incorrect as that container had just been refilled. Cook 5 indicated unsure what was in the aluminum foil with the white crumbs dispersed throughout and proceeded to throw the item in the trash can. On [DATE] at 9:35 A.M., A clear bag of homestyle chicken tenderloin in a bag sitting in a cardboard box was observed. The bag was open, and the box flaps were closed, but created an opening at the top of the box. On [DATE] at 9:37 A.M., 4 (four) red strawberry gelatin packets without individual dates was observed in a box dated [DATE]. At that time, the dietary manager indicated the packets were expired. During an interview on [DATE] at 9:47 A.M., the dietary manager indicated expired foods were supposed to be disposed of every other day, and there was a thorough check every Sunday, but sometimes they missed items. The dietary manager further indicated frozen foods that were open were to be put in a box and closed up the best they could. During an interview on [DATE] at 9:40 A.M., the dietary manager indicated all items should have been labeled with the date received, and if the item was open, labeled with an expiration date. Frozen foods were closed up as well as possible and put in a box. At that time, she indicated the wall in the kitchen started peeling back a month and a half ago and maintenance was aware. During an interview on [DATE] at 10:56 A.M., Regional maintenance indicated he was not aware that the kitchen wall was peeling off and brick was exposed. At that time, Regional maintenance indicated there was not a specific policy for maintenance, however, staff was supposed to fill out a work order that would notify him via a computer system. A current Food Storage policy, revised ,d+[DATE] indicated .Leftover prepared foods are to be stored in covered containers or wrapped securely. The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded .Frozen Foods: .Foods should be covered or wrapped tightly, labeled, and date . 3.,d+[DATE](i)(3) 3.,d+[DATE](i)(2)

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident in order to meet medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Staff did not implement care plan interventions for 1 of 1 residents reviewed for hydration, and 2 of 2 residents reviewed for activities of daily living. (Resident 17, Resident 23, Resident 1) Findings include: 1. On 7/11/22 at 10:50 A.M., Resident 17 was observed lying in bed. A grab bar on the left side of the bed was observed attached and in an upright position. No grab bar was observed on the right side of the bed. A call light was observed lying at the head of the bed above Resident 17's head. Resident 17 was unable to reach the call light when asked to. On 7/12/22 at 1:44 P.M., Resident 17's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent significant change MDS (minimum data set) Assessment, dated 5/10/22 indicated Resident 17 required extensive assistance of 2 (two) staff with bed mobility, and had a severe cognitive impairment. A current risk for falls care plan, last revised 5/17/22, included but was not limited to the following interventions: Grab bar x 2 while in bed (dated 2/26/21), and call light in reach (dated 8/27/20). On 7/13/22 at 9:34 A.M., Resident 17 was observed lying in bed. A grab bar on the left side of the bed was observed attached and in an upright position. No grab bar was observed on the right side of the bed. A call light was observed lying on the floor by the head of the bed. HK (housekeeper) 2 was observed in the room cleaning, left the room with a trash bag, but did not move the call light. CNA (Certified Nurse Aide) 3 was then observed to enter the room with Resident 17's roommate, then left without moving Resident 17's call light. At that time, CNA 3 indicated the call light was supposed to be attached to the bed and within reach of the resident. CNA 3 also indicated the left grab bar on Resident 17's bed was supposed to be in the upright position, but was unsure about a grab bar on the right side of the bed. During an interview on 7/13/22 at 2:51 P.M., the DON (Director of Nursing) indicated the missing grab bar on Resident 17's right side of the bed was noticed by staff, and a work order had been placed to fix it. The issue had been discussed at a morning meeting. A Resident Profile form, dated 4/20/22, was provided with a written note that a work order had been completed for Resident 17's grab bar. 2. On 07/13/22 at 10:15 A.M., Resident 1 was observed resting in bed. The resident's call light was found inside the drawer of the nightstand. On 07/13/22 at 09:04 A.M., Resident 1's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent significant change MDS (minimum data set) Assessment, dated 6/23/22 indicated Resident 1 required extensive assistance of 2 (two) staff with bed mobility, and had a severe cognitive impairment. A current risk for falls care plan, last revised 7/5/22, included but was not limited to the following interventions; call light in reach (dated 2/8/21). 3. On 7/11/22 at 11:40 A.M., Resident 23 was observed sitting in a Broda chair (tilting wheelchair) in his room. A call light was observed lying on the floor out of reach of the resident. On 7/12/22 at 11:41 A.M., Resident 23's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent significant change MDS Assessment, dated 6/28/22, indicated Resident 23 required extensive assistance of 2 (two) staff with bed mobility, and had a severe cognitive impairment. A current risk for falls care plan, dated 3/28/19, included but was not limited to the following interventions: Call light in reach (dated 3/28/19). On 7/14/22 at 9:44 A.M., Resident 23 was observed sitting in a Broda chair in his room. A call light was observed hanging off of the bed frame and out of reach of the resident. During an interview on 7/14/22 at 11:34 A.M., RN (Registered Nurse) 35 indicated there was not a specific policy related to care plan interventions, but the facility policy was to implement care plan interventions. RN 35 also indicated staff was supposed to conduct daily rounds at specific times to check and make sure call lights were within reach of the residents. 3.1-35(g)(2)

Based on observation and record review, the facility failed to ensure the daily posted nurse staffing reflected the actual hours worked by staff for 4 of 4 days of daily posted nurse staffing reviewed. Finding includes: On 7/11/22 at 10:50 A.M., the Posted Nurse Staffing was observed. The Posted Nurse Staffing lacked the actual hours worked. On 7/14/22 at 9:40 A.M., the Posted Nurse Staffing was observed. The Posted Nurse Staffing lacked the actual hours worked. On 7/14/22 at 10:00 A.M., the Nurse scheduler provided the Posted Nurse Staffing for 7/11/22-7/14/22. The Posted Nurse Staffing lacked the actual hours worked. On 7/14/22 at 10:45 A.M., the facility administrator supplied a facility policy titled, Posted Nurse Staffing Data and Retention Requirements, and dated 07/2019. The policy included, 1. The facility must post the following information at the beginning of each shift . d. The total number and actual hours worked by . licensed and unlicensed nursing staff directly responsible for resident care per shift .

Based on observation and interview, the facility failed to ensure food was served in a sanitary manner for 1 of 2 kitchen observations and 1 of 1 meal preparations. Expired food items were in the dry storage and refrigerator, there were open items in the dry storage, refrigerator, and freezer, a dented can was positioned on the can rack with other cans, butter packets were placed directly on food, and handwashing was not performed after touching a trash can. Findings include: 1. On [DATE] at 9:30 A.M., the following was observed in the kitchen: a. A can of cream style corn was positioned on the can rack with a dent covering ¼ of the can. b. Located in the dry storage area, two plates of powdered donuts were labeled with a use by date of [DATE]. Debris under both dry storage racks. c. Two canisters of brown rice with a use by date of [DATE]. d. A cardboard box of lasagna that was open to air. e. In the freezer, an open bag of chicken breast tender fritters sitting in a cardboard box. The kitchen manager indicated at that time the chicken tenders were used the day before, and must have not been closed. f. Located In the refrigerator, a cole slaw container had a use by date of [DATE]. A spaghetti sauce container and shredded cheese container had lids that were not closed all the way with the food items open to air. During an interview on [DATE] at 9:40 A.M., Cook 2 indicated every Sunday, staff would go through all items in the kitchen and dispose of all expired items from the previous week. At that time, the kitchen manager indicated dented cans were not supposed to be on the can rack, and they were supposed to be placed on the shelf by the door to be picked up by the delivery person on their next delivery. The kitchen manager further indicated all items in the freezer and refrigerator were supposed to be closed. 2. During lunch preparation on [DATE] at 11:15 A.M., the following was observed: a. Cook 8 placed butter packets wrapped in hard plastic directly on top of 6 individual bread slices and wrapped them with plastic wrap. b. Cook 8 threw a piece of trash into the trash can, touching the lid with the back of her hand. She then went to the refrigerator and handled 6 trays, taking out 3 of them. Cook 8 then pulled back the plastic wrap on a tray of milk so the temperature could be checked. She then touched her uniform bottoms and top, then put lids on 4 dressing cups. She then placed her eyeglasses in the pepper packet container directly on top of the packets, put lids on 13 drinks, then put her eyeglasses back on. Cook 8 then touched her hairnet, and continued to put lids on bowls. Cook 8 then washed her hands. She was not wearing gloves during that observation. During an interview on [DATE] at 1:59 P.M., the kitchen manager indicated staff should wash their hands in the kitchen after touching something dirty, such as the garbage can, before handling anything else. On [DATE] at 2:25 P.M., the following current policies were provided: Food Storage, revised ,d+[DATE], that indicated in the freezer and refrigerator, food should be covered or tightly wrapped, and dented cans should be disposed of promptly. Food Safety, dated ,d+[DATE], that indicated Good sanitary food handling practices with sanitary conditions maintained in the storage, preparation and serving areas will be carried out at all times 3.,d+[DATE](i)(2) 3.,d+[DATE](i)(3)

Based on observation, interview, and record review, the facility failed to implement infection control prevention measures for 1 of 5 residents observed for care and 7 of 14 rooms observed. Hand hygiene was not completed and gloves were not used, resident care equipment was stored uncovered and unlabeled in shared bathrooms and linen was not transported in a sanitary manor. (Resident 16, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Room ) Findings include: 1. On 5/4/21 at 1:14 P.M., Resident 16 requested to go to the bathroom. LPN 9 was notified and indicated Resident 16 was going to get a shower that afternoon (5/4/21). LPN 9 indicated she would notify the CNA. At 1:17 P.M., CNA 4 was observed to assist Resident 16 to the shower room. CNA 4 donned gloves. CNA 4 assisted resident to pivot to the commode. CNA 4 removed Resident 16's incontinence brief, pants, long sleeved t-shirt, and t-shirt. CNA 4 walked to the shower area and turned on the water. CNA 4 removed her gloves and donned clean gloves. No hand hygiene was observed. CNA 4 assisted Resident 16 to stand. CNA 4 was observed to clean Resident 16's buttocks. CNA 4 assisted Resident 16 to sit in a shower chair. CNA 4 removed her gloves and disposed of the gloves in a trash can across the room. No hand hygiene was observed. CNA 4 was observed to pull her pants, removed Resident 16's slip resistant socks, obtained a clean pair of gloves and placed them in her pocket. CNA 4 took resident to the shower area. CNA 4 asked Resident 16 if the water felt ok. CNA 4 obtained wash cloths, and began to get Resident 16 wet for his shower. Resident 16 indicated the water was a little too hot and CNA 4 adjusted the water. CNA 4 began to get Resident 16 wet for his shower and utilized an ungloved hand to lift Resident 16's abdomen. CNA 4 donned gloves from her pocket. CNA 4 obtained a washcloth and soap and handed the washcloth to Resident 16 to wash his upper body. CNA 4 obtained an additional wash cloth and soap and began to wash Resident 16's abdomen, CNA 4 washed Resident 16's right leg and foot then Resident 16's left leg and foot. CNA 4 utilized the same wash cloth to wash Resident 16's back, left arm and armpit, and right arm and armpit. CNA 4 was observed to wash Resident 16's buttocks. A brown substance was observed on the wash cloth. No glove changes or hand hygiene was observed. CNA 4 threw the washcloth on the shower room floor. CNA 4 was observed to obtain an additional washcloth and soap and washed Resident 16's perineal area. CNA 4 obtained a dry washcloth for Resident 16 to place over his eyes while CNA 4 washed his hair. CNA 4 rinsed Resident 16's hair, utilized the dry was cloth to wipe Resident 16's face. CNA 4 rinsed the rest of Resident 16's body and removed her gloves. CNA 4 threw her gloves in the wash basin. No hand hygiene was observed. CNA 4 obtained shaving cream from the wash basin and utilized a washcloth to wet Resident 16's face. CNA 4 hung the washcloth on the hand rail in the shower. CNA 4 began to place shaving cream on Resident 16's face. No glove use was observed. Resident 16 indicated he was cold. CNA 4 rinsed her hands and obtained a towel to cover Resident 16 with. CNA 4 obtained additional shaving cream for Resident 16's face. CNA 4 rinsed her hands in the shower water and shaved Resident 16's face. CNA 4 placed the used razor on top of the soiled utility bin. CNA 4 obtained the washcloth hanging on the shower chair and wiped the remaining shaving cream from Resident 16's face. CNA 4 obtained the razor sitting on top of the soiled utility bin to finish shaving the areas that were missed on Resident 16's face. CNA 4 placed the razor back on top of the soiled utility bin. CNA 4 turned off the water and began to dry Resident 16 off. CNA 4 assisted Resident 16 to put on his socks, incontinence brief, and pants. CNA 4 dried off Resident 16's hair and back and assisted Resident 16 to put on his shirt. CNA 4 adjusted the residents wheelchair and donned gloves. No hand hygiene was observed. CNA 4 assisted Resident 16 to stand from the shower chair, dried his buttocks, and pulled his pants up. CNA 4 assisted Resident 16 to sit in the wheelchair. CNA 4 removed her gloves. No hand hygiene was observed. CNA 4 assisted Resident 16 to put on a face mask, placed his hat on his head, and picked up the soiled linens with bare hands and placed them in the soiled utility bin. No hand hygiene was observed. CNA 4 opened the door to the shower room and assisted Resident 16 back to his room. 2. On 5/3/21 at 9:45 A.M., room [ROOM NUMBER] was observed. In the bathroom, an unlabeled and uncovered urine hat, bed pan, and wash basin were observed on the floor. An unlabeled and uncovered denture brush was sitting on the sink. On 5/5/21 at 11:18 A.M., the same was observed. Two residents shared the bathroom. 3. On 5/2/21 at 11:11 A.M., room [ROOM NUMBER] was observed. In the bathroom, an unlabeled and uncovered wash basin was observed on the floor. On 5/5/21 at 11:19 A.M., the same was observed. The bathroom was shared by three residents. 4. On 5/3/21 at 1:42 P.M., room [ROOM NUMBER] was observed. In the bathroom, an unlabeled and uncovered denture brush was observed on the sink. On 5/5/21 at 11:33 P.M., the same was observed. The bathroom was shared by three residents. 5. On 5/2/21 at 9:50 A.M., the shared bathroom between room [ROOM NUMBER] and 138 was observed with the following: An uncovered denture brush on the sink. A medicine cup on the sink with a cloudy white substance in the bottom of it. An uncovered wash basin in the floor under the sink with wash cloths in it. During an interview on 5/2/21 at 10:33 A.M., LPN 6 indicated the substance in the medicine cup looked like [MEDICATION(S)], and it should have been thrown away after it was administered to a resident. 6. On 5/2/21 at 9:50 A.M., the shared bathroom in room [ROOM NUMBER] was observed with the following: An open package of wipes was on the back of the toilet with wipes coming out. The garbage can did not have a bag in it. Two uncovered wash basins were stacked together under the sink with a disposable brief in them. The brief had a brown substance on the outside of it. 7. On 5/2/21 at 9:48 A.M., room [ROOM NUMBER] was observed. In the bathroom, an unlabeled and uncovered urine hat, bed pan, and wash basin were observed on the floor. An unlabeled and uncovered toothbrush and a tube of toothpaste was sitting on the sink. On 5/3/21 at 1:49 A.M., a uncovered toothbrush and a tube of toothpaste was sitting on the sink. Three residents shared the bathroom. 8. During a random observation on 5/5/21 at 9:40 A.M., LPN 5 was observed pulling clean towels from the clean linen closet, hugged them against her uniform top, walked them down the hall to room [ROOM NUMBER], walked into the room, and shut the door. During an interview on 5/5/21 at 1:56 P.M., LPN 7 indicated clean linen should be carried away from the body. She further indicated items are not supposed to be on the resident bathroom floors, and items such as denture brushes should be in a plastic bag, and not laying uncovered. On 5/5/21 at 2:21 P.M., a current Storage and transportation of linens and personal clothing policy, dated 8/17, was provided, and indicated When carrying linens they should be carried away from the body and clothing On 5/5/21 at 1:39 P.M., CNA 10 indicated that gloves should be changed and hand hygiene should be performed after perineal care. CNA 10 further indicated gloves should be worn to shave any resident. On 5/5/21 at 2:21 P.M., the Administrator provided the current Hand Hygiene Policy, revised 12/2020. The policy included, but was not limited to: 5 Moments of hand hygiene .Before touching a resident .after body fluid exposure risk, after touching a resident, after touching a residents surroundings .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a resident .before moving from work on a soiled body site to a clean body site on the same resident immediately after glove or PPE [personal protective equipment] removal 3.1-18(b)(1) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure the ice machine located in the kitchen was unclean. This had the potential to affect all 54 residents in the facility. (Kitchen) Findings include: During an observation and interview in the kitchen on 3/7/19 at 9:32 A.M., the ice machine located in the kitchen was observed to have slime with black spots on the plastic ice guard in the ice bin. The Kitchen Manager (KM) indicated there was debris on the plastic cover guard and that the maintenance man was responsible for cleaning the ice machines. The Kitchen Manager indicated she had sent a work order for cleaning the ice machine to the maintenance supervisor over a month ago. The Kitchen Manager provided a Log Book document dated 1/25/19. The Logbook indicated the last time the filters were checked, coils cleaned, interior sanitized, and delimed was on (MONTH) 25 th, 2019. During an observation on 3/13/19 at 11:25 A.M., cold drinks for the hall trays and dining room were prepared using the ice from the ice machine in the kitchen to all residents in the building. During an interview on 3/14/19 at 12:07 A.M., the Maintenance Supervisor (MS) indicated he was supposed to clean the ice machine monthly, but he did not have enough time to complete the task. A policy was provided by the Kitchen Manager on 3/7/19 at 9:45 A.M., and it read as follows: . 1. Sanitize interior of the ice machine per manufacturer's instructions. 2. Clean out and sanitize the ice bin . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to notify the physician for 1 of 2 residents reviewed for insulin use. Notifications of blood sugar readings below set parameters were not sent to a physician. (Resident 52) Findings include: During record review on 3/13/19 at 9:45 A.M., Resident 52's most recent quarterly MDS (Minimum Data Set) assessment, dated 2/20/19, indicated the Resident was receiving insulin and had a [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Resident 52's care plan included, but was not limited to; Resident is at risk for adverse effects of [MEDICAL CONDITION] or [DIAGNOSES REDACTED] related to use of glucose lowering medication and/or [DIAGNOSES REDACTED]. A progress note dated 2/4/19 stated, .checked blood glucose this morning and (it) was 52. Resident stated (Resident) did not feel well. Nurse gave Insta Glucose. Resident requested orange juice. Resident drank 120 (milliliters) of orange juice. Will re assess in 15 (minutes). A progress note dated 3/7/19 stated, .checked resident's blood glucose this morning and (it) was 58.orange juice given. Waited 10 (minutes) and re checked and (it) was 74. Resident is alert and oriented and eating a peanut butter and jelly sandwich. No diabetic distress noted. Will continue to monitor. During an observation on 3/8/19 at 9:30 A.M., Resident 52 was in bed, and appeared drowsy. The Resident was unable to stay awake while answering questions during an interview. During an interview on 3/13/19 at 10:30 A.M., the MDS Coordinator indicated there was no documentation of the physician being notified for low blood sugar readings on 2/4/19 or 3/7/19, and that the physician should be notified if blood sugars are out of given parameters. On 3/13/19 at 11:30 A.M., a facility policy, dated 2/2015, and titled Blood Glucose Monitoring, was supplied. The policy stated, the physician will be notified when the resident's blood glucose is outside the physician stated parameters or if the resident is experiencing signs or symptoms of high or low blood sugar. 3.1-5(a)(1)

Based on observation, interview, and record review, the facility failed to ensure privacy for a resident during a dressing change for 1 of 2 residents observed for pressure ulcer dressing changes. (Resident 53) Findings include: During an observation of a dressing change on 3/13/19 at 9:37 A.M., Resident 53's roommate was sitting in a wheelchair with her back to Resident 53. RN 9 and CNA 16 began the dressing change without pulling the privacy curtain between Resident 53 and the roommate. Resident 53's pants, brief, and a dressing located on the coccyx were removed. Without pulling the sheet up over Resident 53's bottom RN 9 stepped into the bathroom and washed her hands. CNA 16 pulled the sheet up over the resident bottom. CNA 16 indicated the curtain should have been pulled closed before beginning the dressing change. Upon returning from the bathroom RN 9 was made aware that the curtain was not pulled and she indicated it should have been pulled closed. A policy Dressing Change dated 9/2012 was provided by the Director of Nursing on 3/14/19 at 10:11 A.M., and read as follows:: 2. Provide privacy and explain procedure . 3.1-3(o)

Based on observation, interview and record review, the facility failed to provide supervision and assistance to prevent falls for 2 of 4 residents reviewed for accidents. Residents at risk for falls and requiring assistance were left unattended in a restroom while interventions to prevent falls were not in place. This deficient practice resulted in Resident 57 sustaining a fall requiring a staple. (Resident 45, Resident 57) Findings include: 1. On 3/12/19 at 12:22 P.M., Resident 57's clinical record was reviewed. A Significant Change MDS (Minimum Data Set) assessment, dated 10/17/18, indicated Resident 57 had severe cognitive impairment, required extensive assistance of two persons for toileting, and not steady, requiring human assistance while moving on and off the toilet and from a seated to standing position. The MDS further indicated Resident 57 had highly impaired hearing, severely impaired vision, and sometimes understood others. The Care Plans included, but were not limited to: Resident experienced memory deficit with impaired decision making ability, initiated on 1/20/17. Resident at risk for falls, initiated on 10/28/15. A Fall Risk Assessment, dated 10/16/18, indicated Resident 57 was a high risk for falls. The Progress Notes included, but were not limited to: 10/30/18 at 4:28 P.M.: Resident was found on floor by bathroom door laying on right side asleep . 11/12/18 at 1:20 P.M.: Resident had fall in bathroom. Large hematoma noted to left side of residents head. MD (medical doctor) updated, new order rec'd (received) to send resident to the ER (emergency room ) for eval (evaluation) et (and) tx (treatment) 11/12/18 at 1:58 P.M.: IDT (interdisciplinary team) review post fall resident found on bathroom floor after staff heard her fall from the hallway resident was evaluated and small laceration measuring 0.7 cm (centimeters) present on top of her head as well as a hematoma on the left forehead area measuring 6 x (by) 5.5 cm resident sent to ER for evaluation per MD orders .new interventions staff educated to stay with resident throughout the entire toileting process. 11/13/18 at 6:43 P.M.: Resident returned from (name of) hospital this evening via ambulance. MD/family notified. No new orders from MD at this time. Transferred resident from stretcher to chair with sheet Resident responsive but not oriented to person, place, or time. Resident has a raised hematoma to left forehead and a staple to the top of head, open to air On 3/13/19 at 11:25 A.M., the DON indicated on any given day Resident 57 could have probably gotten up off the toilet herself but on 11/12/18 she fell and that answered the question of whether she should have been left in the bathroom unattended. 2. During record review on 3/12/19 at 11:00 A.M., Resident 45's most recent quarterly MDS (Minimum Data Set) assessment, dated 2/15/19, indicated the Resident required extensive assistance with transfers, walking in room, and toilet use. Resident 45 had 2 or more falls since the previous assessment. Resident 45's [DIAGNOSES REDACTED]. Resident 45's care plan included, but was not limited to; Resident is at risk for falls due to weakness and [MEDICAL CONDITION], and requires assist with activities of daily living (ADLs) due to medications, history of falls, unsteady gait, and incontinence. Interventions included, but were not limited to; stay with Resident while toileting (11/13/18), and non-skid footwear (10/19/18). A fall assessment, dated 11/9/18, indicated Resident 45 was a moderate risk for falls. A progress note ,dated 1/1/19, included, .resident was assisted to the restroom per CNA staff. Resident was transferring from the toilet back into (resident's) wheel chair when (resident's) feet got tangled together causing resident to lose (resident's) balance. CNA was able to lighten the impact of the fall but not able to help resident regain (resident's) balance. Resident landed on (Resident's) buttocks, (Right) shoulder hit the bathroom wall.immediate intervention is to donn (sic) gripper socks or shoes during transfers . An IDT (Interdisciplinary Team) note, dated 1/1/19, included, .IDT review post fall without injury. Resident fell while transferring from toilet to (wheelchair). Resident was not wearing footwear at the time of fall. New intervention will be to educate specific staff involved (related to) care plan and transfer procedures. Continue all (previous) interventions. During an observation on 3/14/19 at 8:45 A.M., Resident 45 was assisted by 2 CNA's during a transfer from the wheelchair to the bed. The CNA's used a gait belt around the Resident's waist to help support and stabilize the Resident. During an interview on 3/12/19 at 1:15 P.M., RN 9 indicated the CNA that assisted Resident 45 during a fall on 1/1/19 had left Resident 45 alone to attend to another Resident. When the CNA returned to Resident 45, the Resident was transferring self in the bathroom. The CNA could not use a gait belt before the Resident fell . During an interview on 3/14/19 at 8:50 A.M., CNA 5 indicated staff should not leave residents after assisting them to the bathroom. On 3/12/19 at 1:38 P.M., the Nurse Consultant provided the current Fall Management Program policy, revised 11/2017. The policy included, .ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate catheter care for 1 of 1 residents reviewed for indwelling catheter care. A resident's catheter drainage bag and tubing was observed 4 times lying on the floor. (Resident 41) Findings include: During an observation on 3/7/19 at 9:15 A.M., Resident 41 was observed sitting in her wheelchair in her room. The tubing for her indwelling catheter was lying on the floor. During an observation 3/8/19 at 10:27 A.M., Resident 41 was observed lying in bed. The drainage collection bag was attached to the bedside, but the bed was positioned close to the floor and the end of the catheter drainage bag was on the floor. During an observation on 3/8/19 at 12:48 P.M., Resident 41 was observed sitting on the side of the bed with her bedside table in front of her. The catheter bag was hanging on the bed frame. The tubing for the indwelling catheter was on the floor and the resident's foot was resting on the tubing. During an observation on 3/12/19 at 1:10 P.M., Resident 41 was observed lying in bed The bed was in the low position close to the floor and the catheter bag was sitting on the floor. During an observation and interview on 3/12/19 at 1:15 P.M., the MDS nurse indicated the catheter bag should not have been sitting on the floor. The MDS nurse further indicated there should have been a bed pan under the catheter bag. The clinical record of Resident 41 was reviewed on 3/11/18 at 10:30 A.M. The record indicated the [DIAGNOSES REDACTED]. The most recent quarterly MDS (Minimal Data Set), dated 1/25/19, indicated resident 41 experienced severe cognitive impairment, had an indwelling catheter, and required the assistance of 2 staff for transferring and toileting. Resident 41's clinical record indicated a UTI (Urinary Tract Infection) on 3/9/19. The current physician orders [REDACTED].Twice a Day . 11/23/2018 .Cath orders .Change .Catheter .as needed .DX: Neuromuscular dysfunction of bladder . A care plan dated 11/23/18 and titled, Resident requires an indwelling urinary catheter R/T(related to) [MEDICAL CONDITION] bladder ., stated, .Approach Start Date 11/23/2018 Do not allow tubing or any part of the drainage system to touch the floor . A Quality Assurance Tool provided by NC2 (Nurse Consultant 2) on 3/12/19 at 1:45 P.M., read as follows: .Catheter tubing is not touching or dragging the floor . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure appropriate treatments and services were provided for 1 of 5 residents reviewed for unnecessary medications. Psychiatric services recommended to continue with medication changes for the outcome and the medication was discontinued. (Resident 8) Findings include: On 3/12/19 at 10:38 A.M., Resident 8 was observed sleeping in bed. On 3/13/19 at 9:16 A.M., Resident 8 was observed sleeping in bed. On 3/14/19 at 9:09 A.M., Resident 8 was observed lying in bed. Resident 8 indicated he did not like to go to activities because he did not feel like doing anything but laying in bed. Resident 8 further indicated he used to enjoy television but he didn't even feel like doing that anymore. On 3/12/19 at 10:24 A.M., Resident 8's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) assessment, dated 12/7/18, indicated Resident 8 had no cognitive impairment, suffered from mild depression, and had active [DIAGNOSES REDACTED]. The Care Plans included, but were not limited to: Resident is at risk for signs and symptoms of depression. Resident has a [DIAGNOSES REDACTED]. Resident displaying signs and symptoms of mood distress as evidenced by finding little interest or pleasure in doing things, initiated 12/7/18. Resident is at risk for signs and symptoms of anxiety. Resident has [DIAGNOSES REDACTED]. On 1/14/19 the Care Plan was updated to reflect, Resident becomes verbally aggressive when showing increased anxiety and becomes tearful. The physician's orders [REDACTED]. [MEDICATION NAME] (antidepressant medication) 50 mg (milligrams), by mouth, daily, initiated on 1/22/19. [MEDICATION NAME] (an antipsychotic medication) 0.5 mg, by mouth, daily, initiated on 1/10/19. [MEDICATION NAME] (an antipsychotic medication) 40 mg, by mouth daily, discontinued on 1/10/19. A Pharmacy Consultation Report, dated 9/19/18, indicated Resident 8 received, [MEDICATION NAME] 20 mg daily and [MEDICATION NAME] 0.5 mg two times daily. The Report recommended an attempt to reduce medication including, but not limited to: [MEDICATION NAME] 20 mg every other day for one week then discontinue. The recommendation was declined by the Primary Care Physician because the resident was stable on 10/12/18. A Primary Care Outpatient Note from the Veterans Administration Clinic, dated 1/25/19, indicated Resident 8 had [DIAGNOSES REDACTED]. On 3/13/19 at 2:30 P.M., the Social Worker provided the Psychiatric Progress Notes. The Psychiatric Progress Notes included, but were not limited to: 12/20/18: Interval History: Reports he is 'down'. Feels his pain has improved Thinks he is more depressed, doesn't ever feel like getting out of bed most days. Thinks it has been going off and on for a few months now, mostly due to health decline and living status. Assessment and Plan: Increase [MEDICATION NAME] to 40 mg daily (8/30/18) for increase in depressive symptoms. Continue [MEDICATION NAME] 40 mg daily (8/30/18), reports mild depression and anxiety. 1/7/19: Interval History: Reports he is still very depressed despite recent medication changes. States he does not like living at the facility, wants to go home. Does not feel like doing anything other than laying in bed most of the day. Assessment and Plan: Continue [MEDICATION NAME] 40 mg daily, increased on 12/20/18 for worsening symptoms, await full response to medication increase . 1/22/19: Interval History: (Name of Resident) reports he continues to be tired and not interested in any activities. States no improvement with recent medication changes Assessment and Plan: Increase [MEDICATION NAME] 50 mg daily, has no improvement in symptoms of depression with recent medication changes. [MEDICATION NAME] stopped as GDR (gradual dose reduction) on 1/10/19. Consultation for treatment: Nursing staff: Continue services, [MEDICATION NAME] was stopped as GDR. Increase [MEDICATION NAME] as still with moderate to severe depression at this time. On 3/14/19 at 10:30 A.M., the DON provided the hospital discharge orders, dated 8/30/18. The orders included, but were not limited to: Continue [MEDICATION NAME] by mouth, daily. Continue [MEDICATION NAME] 0.5 mg by mouth two times daily. On 3/14/19 at 8:44 A.M., the Social Worker indicated Resident 8 was evaluated by psychiatric services. The Social Worker indicated the Primary Care Physician had decreased Resident 8's [MEDICATION NAME] and discontinued the [MEDICATION NAME]. The Social Worker indicated behavior tracking was missing because the facility had been in between social workers recently. The Social Worker further indicated if the resident was being evaluated by psychiatric services, psychiatric services should be the one to decrease psychoactive medications. The Social Worker indicated Resident 8 was depressed. On 3/14/19 at 9:55 A.M., the DON indicated on 1/10/19 the Primary Care Physician discontinued Resident 8's [MEDICATION NAME] because no behaviors were documented for four months. The DON indicated the Primary Care Physician based the decision to discontinue the medication upon the Pharmacy Consultation Report from 9/19/18. The DON indicated the Primary Care Physician received all the Pharmacy Consultation Results. On 3/14/19 a 10:42 A.M., the DON indicated he had spoken to the Primary Care Physician who indicated reviewing the psychiatric services consults when making gradual dose reduction decisions. On 3/14/19 at 11:14 A.M., the DON indicated he was aware of Resident 8's [DIAGNOSES REDACTED]. On 3/14/19 at 9:47 A.M., the DON provided the current [MEDICAL CONDITION] Management Policy revised 9/2017. The policy included, but was not limited to; It is the policy of American Senior Communities to ensure that a resident's [MEDICAL CONDITION] medication regimen helps promote the resident's highest practicable mental, physical and psychosocial well-being with person centered interventions and assessment. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure food was served at an appetizing temperature for 3 of 8 residents reviewed for food temperatures. (Resident 39, Resident 3, Resident 47) Findings include: During an interview on 3/08/19 at 9:58 A.M., Resident 39 indicated she ate breakfast in her room and sometimes breakfast was not hot. Resident 39 said, The eggs are cold, and so is everything else. During an interview on 3/07/19 at 10:18 A.M., Resident 3 indicated that she ate in her room and that sometimes the food was not hot. During an interview on 3/07/19 at 11:10 A.M., Resident 47 indicated that 4 out of 10 times his food was served cold, especially breakfast. The third from the last breakfast tray was tested on [DATE] at 7:17 A.M. The temperature of the scrambled eggs was 125 degrees F (Fahrenheit), the hot ham and cheese on toast was 115 degrees F, the bottom piece of toast was soggy, and half of a powdered donut was soggy. During an observation and interview on 3/14/19 at 7:35 A.M., Resident 47 was observed sitting with his food tray in front of him and he indicated that the breakfast was cold. Resident 47 stated, As usual. A policy titled, Food Temperatures, dated 11/17, was provided by The Dietary Manager on 3/14/19 at 7:40 A.M., and it read as follows: .The facility will prepare and serve food at the proper temperature to prevent food borne illness .1. Hot foods that are potentially hazardous will leave the kitchen .at or above 135 degrees .2. All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food . During an interview on 3/14/19 at 7:41 A.M., the Dietary Manager indicated that the resident's food should be palatable when it arrived to the resident's room. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the daily posted nurse staffing reflected the actual hours worked by staff for 6 of 6 days of daily posted nurse staffing reviewed. Findings include: On 3/12/19 at 8:50 A.M., the Posted Nurse Staffing was observed. The Posted Nurse Staffing lacked the actual hours worked. On 3/13/19 at 11:40 A.M., the Posted Nurse Staffing was observed. The Posted Nurse Staffing lacked the actual hours worked. At that time, the Administrator indicated they would change the Posted Nurse Staffing to reflect the actual hours worked by direct patient care staff. On 3/13/19 at 11:59 A.M., the Nurse Consultant provided the Posted Nurse Staffing for 3/7/19-3/12/19. The Posted Nurse Staffing lacked the actual hours worked. On 3/14/19 at 10:11 A.M., the Nurse Consultant provided the FTE Daily Posting Instruction policy, undated. The policy included, but was not limited to: Licensed Nursing Staff Columns (total number of shifts not hours) Unlicensed Nursing Staff Columns (total number of shifts not hours) . Total Hours Columns (total hours not shifts) from the day licensed nursing staff how many hours are RN and how many hours are LPN's total (same for evening and night shift) Total Hours Worked Column (total hours not shifts)

Based on observation, interview, and record review, the facility failed to ensure proper care was provided to a resident admitted with pressure ulcers for 1 of 2 residents reviewed for pressure. (Resident #82)The facility also failed to ensure a dependent resident admitted without pressure ulcers was provided effective interventions to prevent the development of a stage 3 pressure ulcer on the right buttock, stage 3 pressure ulcer on the 5th toe right foot, and an unstageable pressure ulcer on the 4th toe right foot for 1 of 2 residents who met the criteria for review of pressure ulcers. This deficient practice resulted in Resident #1 experiencing two stage 3 pressure ulcers and one unstageable pressure ulcer. (Resident #1, Resident #82) Findings include: 1. During an observation on 12/15/15 at 10:46 A.M., Resident #1 was observed in bed, without socks, no blue foot protectors, and a blue round pad (foot elevator foam rings) wrapped around each ankle. At that time, Resident #1's toes on the right foot had no dressing in place and the contractured right foot was observed to be in contact with the mattress. The clinical record of Resident #1 was reviewed on 12/15/15 at 1:30 P.M. The clinical record indicated Resident #1 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #1 experienced severe cognitive impairment, was totally dependent for bed mobility, transfers, and was at risk for developing pressure ulcers. During an interview on 12/16/15 at 9:49 A.M., the Director of Nursing (DON) indicated all residents in the facility were considered at risk to develop pressure ulcers. The Care Plan for Resident #1 dated 10/5/15 was provided by the DON on 12/16/15 at 2:45 P.M., and it read as follows: Resident has impaired skin integrity: shear on right little toe, and buttocks .scab R (right) 4th toe. 12/15/15 .Approach Start Date: 10/5/15 Incontinent care as needed with peri wash and moisture barrier .Labs as ordered .Pressure reducing/redistribution mattress on bed .Supplements as ordered .float heels foam boots 11/18/10 .Turn and reposition every 2 hours .Wound healing vitamins as ordered .Composure (pressure reducing mattress) 12/15/15 . The Care Plan dated 10/5/15 was provided by the DON 12/16/15 at 2:45 P.M., read as follows: Category: Pressure Ulcer .Resident is at risk for skin breakdown related to immobility, contractures, inability to turn self, history of open areas .donuts under heels while in bed Heel protectors .house barrier - use as needed .Prop Legs up on pillows above waist while in bed .Staff must anticipate needs, Resident unable to communicate . The Current physician's orders [REDACTED]. .BIL (bilateral) HEEL PROTECTORS ON AT ALL TIMES . Dated 10/2/15. .MAY USE HOUSE BARRIER CREAM EVERY SHIFT TO O/A (R) BUTTOCKS Dated 11/13/15. .PROP LEGS UP WITH PILLOWS WHEN IN BED ABOVE WAIST AS MUCH AS POSSIBLE . Dated 11/18/15. .FOAM RINGS TO (B) (bilateral) FEET TO ELEVATE OFF MATTRESS WHEN IN BED . Dated 7/28/11. .FORTIFIED FOOD TWICE A DAY . Dated 7/30/15 .TAB-A-VIT TABLET GIVE 1 TABLET ORALLY ONCE A DAY . Dated 4/22/10. .VITAMIN C 500 MG TABLET GIVE 1 TABLET ORALLY 2 TIMES A DAY FOR WOUND HEALING . Dated 9/22/10. The laboratory Cumulative Report dated 10/14/15 indicated Resident #1's lab values (blood levels) were as follows: Total protein was low at 5.5 g/dl (grams per deciliter). The normal range for protein is 6.4 - 8.2 g/dl. [MEDICATION NAME] was low at 2.6 g/dl. The normal range for [MEDICATION NAME] is 3.0 - 4.8 g/dl. The laboratory Cumulative Report dated 11/11/15 indicated Resident #1's lab values (blood levels) were as follows: Total protein was low at 6.1 g/dl. The normal range for protein is 6.4 - 8.2 g/dl. [MEDICATION NAME] was low at 2.8 g/dl. The normal range for [MEDICATION NAME] is 3.0 - 4.8 g/dl. The laboratory Cumulative Report dated 12/9/15, indicated Resident #1's lab values (blood levels) were as follows: Total protein was low at 5.5g/dl. The normal range for protein is 6.4 - 8.2 g/dl. [MEDICATION NAME] was low at 2.9 g/dl. The normal range for [MEDICATION NAME] is 3.0 - 4.8 g/dl. The ASC Nutrition Risk Assessment form dated 12/8/15 indicated the following for Resident #1 .Ability to feed self .Total dependence .Skin conditions .shearing . The assessment form lacked any documentation related to resident #1 had a low protein or that a supplement had been added. The PHYSICIAN TELEPHONE ORDERS dated 12/18/15 documented an order for [REDACTED]. The CNA ASSIGNMENT SHEET STATION 2 was provided by CNA #6 on 12/14/15 at 8:46 A.M., and it read as follows: .bed next to wall, scoop, check and change q (every) 2 hours .use donuts to feet in bed .use draw sheet or lift pad to prevent shearing . The CNA assignment sheet lacked documentation of the following interventions, bilateral heel protectors on at all times, prop legs up with pillows when in bed and above waist as much as possible. During an observation of a treatment on 12/15/15 at 3:01 P.M., RN #6 removed Resident #1's wet brief and cleaned the area on Resident #1's coccyx and buttocks with a peri wipe cloth. RN #6 indicated at that time she thought the area on Resident #1's right buttock was caused by shearing a couple of weeks ago. RN #6 indicated the DON was the wound care nurse and that the DON had measured all skin areas. The wound on the right buttock appeared as a full thickness tissue loss with a pink wound bed and a small amount of tan slough noted on the bed. A brown area was noted on right side of the wound. RN #6 further indicated Resident #1 had a history of [REDACTED]. At that time, no socks or blue heel protectors were observed on the right foot or left foot. A blue padded circle (donut) was wrapped around each ankle. The 5th toe had no dressing in place. The wound appeared to be a 1 cm diameter full thickness tissue loss with pink/white/brown wound bed. The 4th toe on the right foot had an area 1/2 cm in diameter which was covered with a brown scab and no wound bed was visible. RN #6 indicated that even though the 4th toe was presently scabbed over, Resident #6 frequently rubbed the scab off by moving around in the bed. The 3rd toe had a small red area which was blanchable. During an observation of Resident #1's shower on 12/16/15 at 10:20 A.M., CNA #12 indicated she would finish washing Resident #1's peri area when she returned to the room and laid Resident #1 down on the bed. CNA #12 indicated she had washed Resident #1's barrier cream off with a soapy washcloth in the shower, but indicated there was still a little white left in the wound. CNA #12 said, It's hard to get that off. After CNA #12 and CNA #10 used the Hoyer lift and placed Resident #1 on the bed, CNA #12 took a wet, soapy washcloth and vigorously washed the wound bed and the area around the wound removing some of the white and tan material that was on the wound bed. The wound bed was bright red with dots of blood noted on the red tissue. The right side of the wound had a small brown area. CNA #12 then took the INZO barrier cream with the 5% demethicone and zinc oxide and applied it liberally to Resident #1's open wound bed and buttocks. During an interview with CNA #12 at that time, CNA #12 indicated that CNA's applied the cream after they showered Resident #1 and whenever they changed Resident #1's depends. The 5th toe on the right foot was opened and slightly bleeding. It had slough and a brown area covering part of the wound. The 4th toe on the right foot had a brown 0.5 cm round wound. During an observation at 12/16/15 at 12:05 P.M., the DON opened Resident #1's brief and indicated she had not staged the area on Resident #1's buttock and right toes because they were the result of shearing. The DON was made aware of the small pinpoint spots of blood on Resident #1's brief where it had covered the wound on the right buttock. The DON took her gloved finger and removed the barrier cream covering the wound indicating the wound looked better. The wound appeared as a full thickness tissue loss. There was a small amount of tan slough which covered part of the wound bed. The right side of the wound had a small brown area. The right foot was observed to have a dressing, sock, blue heel protectors and the heel rested in the center of the blue round donut. The DON removed the sock and dressing from Resident #1's right foot and observed the wound indicating that the wound appeared soupy because of the [MEDICATION NAME]. During an interview the DON at that time, the DON indicated she had found the blue heel protectors in the closet and put them on Resident #1. The DON further indicated they had a difficult time keeping a dressing on Resident #1's toes because Resident #1 knocked them off. The DON indicated she would measure Resident #1's wounds on 2/17/15. Pressure ulcer right 5th toe: The ASC New Skin Event form dated 9/29/15 was provided by the DON on 12/16/15 at 2:45 P.M., and it indicated that Resident #1 experienced shearing on the right 5th toe measuring 2 cm (centimeters) x1.7 cm x 0.1cm. The wound was described as open bright red with small amount of blood. Treatment was [MEDICATION NAME] and band aid twice a day and preventive measures were to place bilateral feet in blue donuts to keep feet off bed. The ASC Non-Pressure Wound Skin Evaluation Report dated 9/29/15 was provided by the DON on 12/16/15 at 2:45 P.M., and it indicated Resident #1 had developed an area of shearing to the right 5th toe measuring 2 cm x1.7 cm x 0.1 cm. The wound was described as pink and bleeding. The order was [MEDICATION NAME] and band aid twice a day. The Progress Note dated 9/29/15 at 11:00A.M., read as follows: Noted area R (right) little toe open - looks to be a shearing from moving resident in bed . The Progress Note dated 9/30/15 at 10:00A.M., read as follows: IDT (Interdisciplinary Team) members present Reviewed area on toe .area on toe superficial and pink. Area looks sheared Blue donuts in place on bed to lift feet (arrow up) and prevent shearg (sic) when repositioning . The Progress Note from the Nurse Practitioner dated 10/2/15 read as follows: .Abrasion .right 5th toe, getting worse from moving around on the bed, currently bleeding .Float .heels to keep them from rubbing on the sheets .Heel boots are not in place today . The Progress Note dated 10/17/15 at 2:10 P.M., read as follows: .Tx (treatment) continues to toe. Rubs foot against bed et (and) bandage becomes dislodged . The ASC Non-Pressure Wound Skin Evaluation Report dated 10/22/15 indicated the wound on Resident #1's right 5th toe measured 1.5 cm x1.0 cm x 0.1 cm. The wound was described as pink and bleeds at times. The treatment was [MEDICATION NAME]. The Progress Note dated 10/23/15 at 10:30 A.M., read as follows: IDT member present. Area on toe healing. Tissue pink et granulation noted. Bil (bilateral) heel protectors on and floating feet to prevent further shearing in bed . The Progress Note dated 10/26/15 untimed, read as follows: .5th toe area dry and scabbed, heels floated while in bed . The Progress Note dated 10/29/15 at 5:00 A.M., read as follows: .Treatment to 5th toe cont (continues) .area remains open .lg (large) amt (amount) serous drng (drainage) noted . The Progress Note dated 10/29/15 at 10:30 A.M., read as follows: IDT member present. Area R (right) 5th toe remains open .Wears bil (bilateral) heel protectors and uses donuts to elevate feet to keep off of bed . The Progress Note from the Nurse Practitioner dated 11/13/15, read as follows: Problem #1 - Description .2 cm in diameter. Stage II. (two) Bleeding .Right Lower Extremity - fifth toe . Problem #2 .Open area on .coccyx. Dime size, staff using house barrier cream currently . .Lower Extremity .No [MEDICAL CONDITION] (Pedal pulse bilateral and equal. Skin temperature .Heel boots are not in place today . The ASC Non-Pressure Wound Skin Evaluation Report dated 12/10/15, indicated the wound on Resident #1's right 5th toe was caused by schearing and measured .3 cm (centimeters) x .3 cm x 0.1 cm. The wound was described as scabbed. The treatment was [MEDICATION NAME]. The ASC Pressure Wound Skin Evaluation Report dated 12/17/15, was provided by the DON on 12/18/15 at 10:16 A.M., and it read as follows: R (right) 5th toe .existing area .Date area originally noted 9/29/15 .Stage III (three) .Slough .sm (small) amt (amount) thin white . (Yellow or white tissue adhering to ulcer bed) .1.3 (cm) x 1.0 (cm) x 0.1 (cm) .Describe wound color .pink with white slough .Current treatment [MEDICATION NAME] and cover . Pressure ulcer to right buttock: The Progress Note dated 11/13/15 at 10:08 A.M., read as follows: Shear noted on R (right) buttocks .N/O (new order) noted new tx (treatment) to R buttocks . The ASC New Skin Event form dated 11/13/15 indicated Resident #1 experienced shear on the right buttock measuring 1.5 cm (centimeters) x .7 cm x 0.1 cm. The area was open and not draining. Preventative measures were to continue to turn and reposition every 2 hours and lift with a draw sheet or pad. The ASC Non-Pressure Wound Skin Evaluation Report dated 11/13/15, indicated Resident #1 had developed an open area to the right buttock measuring 1.5 cm x .8 cm x 0.1 cm. The wound was described as pink. The treatment order documented was for house cream every shift. The Progress note dated 11/23/15 at 3:00 A.M., read as follows: .house barrier cream applied to buttocks. R (right) side area scabbed, L (left side remains reddened . The ASC Non-Pressure Wound Skin Evaluation Report dated 12/10/15 indicated Resident #1 had an area of shearing on the right buttock measuring 0.6 cm x 0.4 cm x 0.1 cm. The wound was described as pink and healthy tissue. The treatment order documented was house barrier cream. The Progress Note dated 12/15/15 at 5:00 P.M., read as follows: .Reported to DNS (Director of Nursing Services) from day nurse area R buttock has sml (small) amt (amount) scabbed area .Area on toe scab off with no drainage noted . The ASC Pressure Wound Skin Evaluation Report dated 12/17/15 was provided by the DON on 12/18/15 at 10:16 A.M., and it read as follows: R (right) buttock .existing area .Date area originally noted 11/13/15 .Stage III (three) .Slough .sm (small) amt (amount) (Yellow or white tissue adhering to ulcer bed) .1.0 (cm) x 0.5 (cm) x 0.1 (cm) .Describe wound color .pink with sm. amt white slough .Current treatment house barrier - changed to Santyl and [MEDICATION NAME] and cover . Pressure ulcer to right 4th toe: The Progress Note dated 11/15/15 at 5:15 A.M., read as follows: .Scabbed area on R (right) 4th toe noted .0.5 x 0.5 scabbed. will continue float heels. foam boots. to prevent (illegable) rubbing against bed. The ASC Non-Pressure Wound Skin Evaluation Report dated 12/15/15 indicated Resident #1 had a new area of scabbing on the right 4th toe measuring 0.5 cm x 0.5 cm. The wound was described as pink. The current treatment order documented was skin prep. The ASC Pressure Wound Skin Evaluation Report dated 12/17/15 was provided by the DON on 12/18/15 at 10:16 A.M., and it read as follows: R (right) 4th toe .existing area .Date area originally noted 12/15/15. Unstageable .Necrotic/eschar (Black, brown or tan tissue adheres to wound bed) .0.5 (cm) x 0.4 (cm) .not opened .dk (dark) brown/red intact .Current treatment skin prep . During an interview on 12/17/15 at 10:00 A.M., CNA #6 indicated they placed Resident #1's feet on top of the donuts because Resident #1's toes touched the mattress whenever the donut was placed around the resident's ankles. CNA #6 further indicated that when she reported to work this morning she observed Resident #1's feet had fallen off the donuts and were on the mattress. During an observation on 12/17/15 at 11:35 A.M., the DON and the DNS Specialist completed the weekly measurement of Resident #1's wounds. At that time, the DNS Specialist indicated that if a stage 2 pressure ulcer had any slough on the wound bed it should be classified as a stage 3 pressure ulcer. The wound on Resident #1's right buttock and 5th toe right foot were determined to be Stage III (three) pressure ulcers and the 4th toe on the right foot was determined to be an unstageable pressure ulcer. At that time the DON was made aware there were observations of CNA's applying INZO barrier cream to the wound bed and that they were using soapy washcloths to wash the wound bed, after incontinence care, and during showering. The DON indicated at that time that only nursing staff should be performing treatments to pressure ulcers. During an interview with the DNS on 12/17/15 at 1:30 P.M., the DON indicated no manufacturer's information could be provided for the donut ring (foot elevator foam ring) or for the use of the INZO barrier cream as a treatment for [REDACTED]. A Policy and Procedure for SKIN MANAGEMENT PROGRAM was provided on 12/16/15 at 2:53 P.M. by the DON. The procedure read as follows: 1 .The facility assigned wound care nurse will complete further evaluation of the wounds identified and complete the appropriate skin evaluation event on the next business day . The DON at that time indicated she used the ASC Pressure Wound Skin Evaluation Report to determine the stages of a pressure wound. 2. On 12/15/15 at 8:05 A.M., Resident #82 was observed lying in bed with boots applied to the bilateral lower legs. The boots were observed to be improperly applied and the left heel was observed to not have complete pressure relief. During an interview on 12/15/15 at 10:33 A.M., RN #7 indicated Resident #82 was admitted to the facility on [DATE] with multiple pressure ulcers. RN #7 further indicated Resident #82 utilized special boots to provide pressure relief to the heels, and skin prep was applied to the heels for protection. During an interview on 12/15/15 at 11:42 A.M., RN #8 indicated Resident #82 was admitted to the facility with a Stage 4 pressure wound to the left trochanter and two deep tissue injuries. On 12/16/15 at 8:10 A.M., Resident #82 was observed lying in bed with boots applied to the bilateral lower legs. The boots were observed to be improperly applied and the left heel was observed to not have complete pressure relief. The clinical record of Resident #82 was reviewed on 12/16/15 at 9:00 A.M. The record indicated Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission physician's orders [REDACTED].keep heels floated q (every) shift . A Care Plan for Pressure Ulcer dated 12/4/15 included, but was not limited to interventions of, .float heels-boots .turn and reposition every 2 hours . The Plan lacked any documentation to indicate the assistance required for turning and repositioning. A Physician's Telephone Order dated 12/5/15 indicated a new order was received for, .L (left) heel skin prep heel .Wear .boots and float heels while in bed . The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #82 experienced moderate cognitive impairment, required the extensive assistance of two staff for bed mobility, was at risk to develop pressure ulcers, was admitted with unhealed Stage 2, Stage 4, and 2 deep tissue injury pressure ulcers, received pressure ulcer care, and pressure reducing devices. During an interview on 12/16/15 at 9:49 A.M., the DON (Director of Nursing) indicated Resident #82 required the extensive assistance of 1 staff for slight adjustments in positioning while in bed and required the extensive assistance of two staff for complete adjustments in positioning while in bed. On 12/16/15 at 2:20 P.M., Resident #82 was observed lying in bed with boots applied to the bilateral lower legs. The boots were observed to be improperly applied and the left heel was observed to not have complete pressure relief. During an observation of care on 12/17/15 at 9:18 A.M., Resident #82 was observed lying in bed in a supine position. The DON (Director of Nursing) was observed to reposition Resident #82 to the right side by grasping a pad underneath and pulling the resident across the surface of the bed. The DON was then observed to expose the Left heel wound and rub the wound bed with a gloved finger and indicated the wound was closed. The DON was then observed to exit the room, return with a flashlight. During an interview, at that time, the DON indicated she was going to measure the left heel wound. The left heel wound bed was observed to be dark pink with a red, shiny center and measured 0.9 cm (centimeters) length X 2.0 cm width X 0.3 cm depth. The DON then indicated RN #7 would return to perform the treatment and the current treatment was to apply skin prep on the intact skin around the wound for protection. The DON was then observed to exit the room. On 12/17/15 at 9:30 A.M., RN #7 was observed to enter the room of Resident #82. During an interview, at that time, RN #7 indicated the current treatment for [REDACTED]. RN #7 then stated, I am very into prevention. RN #7 then indicated she needed to get the skin prep and was observed to exit the room. RN #7 was then observed to re-enter the room of Resident #82, perform handwashing, and apply gloves. RN #7 was observed to apply skin prep directly to the open wound. Resident #82 was observed, at that time, to grimace. A Policy and Procedure for Wounds provided by the DON on 12/16/15 at 3:09 P.M. lacked any documentation related to dressing change techniques. During an interview, at that time, the DNS Specialist indicated no specific policies for positioning or proper wound care technique could be provided because it was common nursing knowledge and basic standards of practice. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to apparently ensure 2 staff members assisted a resident with a transfer with a hoyer lift, potentially resulting in a fractured left humerus, for 1 of 3 residents reviewed who required a mechanical lift for transfers, in a sample of 4. Resident A Findings include: 1. On 3/5/14 at 8:55 A.M., during the initial tour, Resident A was observed sitting in a broda chair. His left arm was in a splint, and resting on a pillow. The Director of Nursing (DON) indicated at that time that the resident had a fractured left upper arm. The DON indicated the resident ' s left arm had been contracted, and staff observed a change in the appearance of the arm. The DON indicated the facility did an investigation, and couldn't ' t determine the cause of the injury. On 3/5/14 at 9:45 A.M., the Administrator provided documentation regarding the investigation of Resident A's fracture. Included was a statement from LPN # 1, undated, which indicated: "On [DATE]th in the afternoon - (Resident A) was in bed lying on back - (CNA # 1) was with him - she was placing brief on him. I asked if she needed help (and) she said yes. I helped (with) brief (and) straighten (sic) him in bed. CNA asked if resident (left) shoulder could be out of place. I (checked) (left) shoulder (and) arm - could not feel or see anything that seemed unusual - (left) arm was still contracted. Resident did not yell during exam." Additional documentation from CNA # 1, dated 2/3/14, indicated, "On Wednesday (1/29/14) when me and (LPN # 1) put (Resident A) to bed that his arm was flopping around (sic) and I asked her is it broke or out of socket she felt up and down on his arm and couldn't feel anything and he didn't hollar (sic). On Thursday (1/30/14) I didn't notice anything different except he was hollaring more I asked him what was wrong he said somebody had a hold of his elbow. And he was already up both days when I got here Wednesday and Thursday." The clinical record of Resident A was reviewed on 3/5/14 at 10:45 A.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 12/3/13, indicated Resident A scored a 5 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two+ staff for transfer, and had range of motion limitations of "Upper extremity, Impairment on one side." A resident care plan, dated 12/3/13, indicated: "Problem, Potential or Actual ADL (activities of daily living)/Mobility deficit...r/t (related to): CVA, Cognitive Impairment...As evidenced by: Generalized weakness, Contractures...Interventions, Provide assistive device as needed for transfer: ML (mechanical lift)...." Progress notes included the following notations: 1/30/14 at 9:30 P.M.: " Contacted (name of physician) for orders to x-ray (left) shoulder et (and) (left) humerus due to flaccid movement to RO (rule out) dislocation or break of (left) arm. Res (resident) shows s/s (signs and symptoms) of pain when moving (left) arm around. (Physician) agreed to have (x-ray company) come to x-ray (left) arm et shoulder. (X-ray company) contacted et x-ray ordered. DON (name) also contacted to make aware of (change) in condition of (left) arm. " 1/31/14 at 12:00 A.M.: " Paged (physician), x-ray (left) arm shows fx (fractured) left humerus. New orders rec ' d (received). " 1/31/14 at 12:30 A.M.: " Ice packs applied to (left) (upper) arm d/t (due to) (increased) swelling. Pain med given @ 12 M et res. cont. to be in pain from (left) humerus fx ..." 1/31/14 at 2:00 A.M.: "Lortab 10/325 mg given at this time...Cont. to be in pain. Grabs at (left) arm when repositioning. (Left) arm cont. (with) swelling et bruising noted to anticubital (sic) area et inner arm area...." 1/31/14 at 3:00 A.M.: "Paged (name of physician) et informed him of pain meds res. rec'd (received) et cont. to have (increased) pain. Order rec'd to send to ER...." 1/31/14 at 3:15 A.M.: "Res. son (name) informed of res. condition et order rec'd to send to ER." The resident was transferred to theER on [DATE] at 4:00 A.M., and returned to the facility on [DATE] at 4:50 A.M. An ER record, dated 1/31/14 at 4:16 A.M., indicated, "Fracture (Left) humerus shaft...." On 3/5/14 at 3:40 P.M., during interview with LPN # 1, she indicated she was working the day shift on 1/29/14. She said she helped CNA # 1 turn and reposition Resident A while he was in bed. LPN # 1 indicated she did not assist CNA # 1 transfer the resident to bed. LPN # 1 indicated she was unsure who assisted CNA # 1 with the hoyer transfer, as CNA # 2 was gone at an appointment. LPN # 1 indicated CNA # 1 asked her to check the resident's arm to see if it was dislocated. LPN # 1 indicated CNA # 1 did not tell her why she wanted her to check it. LPN # 1 indicated she felt up and down the resident's arm 3 times, and the resident did not appear in pain. She indicated she did not note anything was wrong at that time, and that his arm was contracted as usual. On 3/6/14 at 9:25 A.M., during interview with CNA # 1, she indicated she was taking care of Resident A on 1/29/14. She indicated she "noticed his left arm flopping." She indicated the resident usually held his left arm against his side with his right hand. CNA # 1 indicated LPN # 1 assisted her in placing the resident to bed, and she asked LPN # 1 to check the resident's arm, which she did. CNA # 1 indicated 3 different times that LPN # 1 assisted her in transferring the resident to bed with a hoyer lift. She indicated CNA # 2, who was working that hall with her, was gone at an appointment. CNA # 1 indicated when she worked the next day, Resident A was holding his left arm "as usual," and did not appear in pain. On 3/6/14 at 11:15 A.M., during interview with the Administrator, she indicated it was facility policy to have 2 staff members present during a mechanical lift transfer. The Administrator indicated she had not noticed the discrepancy between CNA # 1 and LPN # 1 regarding assistance with transfers. The Adminsitrator indicated she felt that the fracture may have accidentally occurred during transfer or care, and staff had been inserviced on proper turning and transfer techniques. 2. On 3/6/14 at 11:35 A.M., the Administrator provided the current facility policy on "Ergonomics-Minimal Lift Program, revised July 2012. The policy included: "The Dependent (DL) or Total mechanical lift (TL) may be used for residents who cannot reliably bear weight and can only offer minimal assistance with transfers, and will also be used for all clinically appropriate residents who have fallen and cannot get up independently...The DL or TL mechanical lift is completed with minimum assistance of two...." This Federal tag relates to Complaint IN 800. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide assistance for a dependent resident at risk for falls, resulting in a fall with a head laceration, for 1 of 3 residents reviewed for falls, in a sample of 3. Resident A Findings include: 1. On 10/16/13 at 9:15 A.M., during the initial tour, Resident A was observed lying in bed. Black and purple bruising was observed above and around her left eye, with sutures above her left eyebrow. Resident A indicated, "My head met the floor." On 10/16/13 at 9:30 A.M., the Administrator provided a list of residents, indicating those residents considered interviewable. Resident A was included as being interviewable. On 10/16/13 at 10:45 A.M., the clinical record of Resident A was reviewed. [DIAGNOSES REDACTED]. A Nursing Admission Assessment, dated 9/24/13, indicated the resident was alert and oriented to person, place and time. The assessment indicated the resident had weakness "all over," "cannot walk yet," and required extensive assistance of 2 for transfer and toilet use. A Minimium Data Set (MDS) assessment, dated 10/1/13, indicated the resident scored a 15 out of 15 for mental status, indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two + staff for bed mobility, transfer, and toilet use. A test for "Balance During Transitions and Walking" indicated "Not steady, only able to stabilize with staff assistance." A Physical Therapy progress note, dated 10/8/13, included: "...Gait Tasks: Assistive Devices, The patient requires front wheeled walker and contact guard assist (contact with patient due to unsteadiness) for safe ambulation...Pt. (patient) continued to demonstrate impairment with her functional mobilities, lack of coordination, (positive) postural balance deficits, (positive) muscle strength deficits, decreased functional activity tolerance affecting pt's safety placing pt. @ risk for falls & further decline with functional mobilities...Required assistance in all mobilities with cueing for safety...Precautions: Low endurance - needs frequent rests. Visual deficits...Fall precautions; O2 (oxygen)...." A computerized progress note, dated 10/12/13 at 8:50 A.M., included: "Resident was being transferred from the BSC (bedside commode) to the bed. Resident started to slide with staff holding onto her with the gaitbelt. Staff easied (sic) resident to the floor and at that point she hit her head on the corner of the bed. Staff assisted resident back (sic) to bed after being checked out. Resident does have a laceration of 1.5 cm (centimeters) to forehead above left eye. Resident sent to ER for eval (evaluation)...Alert, Oriented to Person, Oriented to Place...Is there pain? Yes...Laceration and hematoma to left side of head...." An incident report, dated 10/12/13, included: "...Was Resident being transferred at time of incident? Yes...What type of assistance was required when getting up? 2A (assistance of 2). What action(s) were taken following the incident?...Education - Staff...." A "DCR" progress note, dated 10/14/13 and untimed, indicated, "DCR in regards to Res (resident) being transferred et (and) started to slide et staff attempted (sic) to lower her (and) she bumped her head causing a small laceration. Resdient sent to ER for tx (treatment) (and) returned. Rooms moved to give resident more room (illegible) clutter to prevent further incidents...." A care plan, initially dated 9/24/13, indicated: "Fall/Injury Risk related to: Sensory Impairment Factors visual, Pharacological Factors...pain, stiffness, unsteady, poor wt. (weight) bearing, weakness...Interventions, Ambulation 2A, changed on 9/27/13 to 1A (one assist), Transfer: 2A, changed on 9/27/13 to 1A...10/12/13 Room clutter free as possible...." On 10/16/13 at 2:00 P.M., Resident A was interviewed. Resident A indicated on 10/12/13, a CNA was assisting her to walk "from her bed toward the door." Resident A indicated the CNA did not have a gait belt on her, nor had the resident's walker to assist her. Resident A indicated, "I hit the floor." Resident A indicated she required 6 stitches, and that her head "really hurt." Resident A indicated she "didn't want to get anyone in trouble." On 10/16/13 at 3:20 P.M., LPN # 1 was interviewed. LPN # 1 indicated she was in the dining room on 10/12/13 at approximately 8:45 A.M, when she heard CNA # 1 yell for help. LPN # 1 indicated she entered the room and found Resident A on the floor and her head was bleeding. LPN # 1 indicated CNA # 1 informed her she was transferring Resident A from the bedside commode to the bed, and the resident slid down to the floor and hit the corner of the bed. LPN # 1 indicated she was not in the room at the time of the fall, and was reporting what CNA # 1 told her. On 10/17/13 at 9:10 A.M., CNA # 1 was interviewed. Regarding the fall on 10/12/13, she indicated she had already transferred Resident A from the commode to the bed. She indicated the resident was sitting on the side of the bed, and she went to the door to yell at someone else to help her position the resident up in bed. She indicated the resident "was just behind the curtain." On 10/17/13 at 10:45 A.M., during interview with the Administrator and Director of Nursing (DON), they each indicated they were told that the resident was being transferred from the commode to the bed, and the clutter in the room contributed to the fall. The DON indicated she did not think the resident had a walker in her room, because the staff did not ambulate her. The DON indicated the resident usually had a gait belt on her at all times, even while in bed. The Administrator and DON indicated they had not spoken with CNA # 1 regarding the resident's fall. 2. On 10/17/13 at 11:10 A.M., the Administrator provided the current facility policy on "Falls and Injuries," revised April 2012. The policy included: "...strives to provide an environment that is free from hazards...and provides supervision and assistance devices to each resident to prevent avoidable accidents...Centers are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual residents assessed needs and identified hazards in the resident environment...." This Federal tag relates to Complaint IN 499. 3.1-45(a)(2)

Based on record review and interview, the facility failed to monitor for side effects and potential cumulative effects related to administration of pain medications and a muscle relaxer for 1 of 3 sampled residents reviewed for pain medication which led to the resident becoming non-responsive and being sent out to the emergency room by ambulance. (Resident A) Findings Include: Review of the closed clinical record of Resident A on 10/12/11 at 10:10 a.m., indicated: Resident A had [DIAGNOSES REDACTED]. A physician's telephone order, dated 08/16/11, (date of Resident A's admission to facility) indicated Resident A was to have her oxygen concentration checked every shift and was also to have oxygen at 2 liters per nasal cannula to keep her oxygen saturation over 88%. An admission physician's orders [REDACTED]. Review of a 2010 Nursing Spectrum Drug Handbook indicate [MEDICATION NAME] had side effects which included, but were not limited to, sedation, low blood pressure and slow heart rate. The drug handbook indicated [MEDICATION NAME] had side effects which included, but were not limited to, sedation, lethargy, low blood pressure, slow heart rate, [MEDICAL CONDITION], slow and shallow respirations. A Physician Notification sheet, dated 08/18/11, indicated, "...(Resident A) getting [MEDICATION NAME] (sic) 4 mg ii (2) q (every) 4 (hour sign symbol) for pain - Tyl (Tylenol) 325 (mg) 2 between - she states this isn't effective for her pain - any suggestions!" A physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of a 2010 Nursing Spectrum Drug Handbook indicated side effects of [MEDICATION NAME] included, but were not limited to, fatigue, confusion, difficulty speaking, low blood pressure and palpitations. The drug handbook indicated when taking [MEDICATION NAME] nursing should "Observe closely for signs and symptoms of overdose (drowsiness, light-headedness,dizziness, respiratory depression, especially during initial screening....Advise patient to take oral dose with food or milk." A PRN (as needed) [MEDICATION NAME] record/pain flow sheet indicated Resident A received 8 milligrams of [MEDICATION NAME] on the following dates and times: 08/16/11 at 4:45 a.m. 08/17/11 at 12:30 a.m., 08/17/11 at 5:00 a.m., 08/17/11 at 9:00 a.m., 08/17/11 at 1:15 p.m., 08/17/11 at 5:15 p.m., 08/17/11 at 9:15 (does not indicate a.m. nor p.m.), 08/18/11 at 1:30 a.m., 08/18/11 at 6:30 a.m., 08/18/11 at 10:30 (does not indicate whether a.m. or p.m.), 08/18/11 at 2:30 p.m., 08/18/11 at 6:30 p.m. 08/19/11 at 2:50 a.m., 08/19/11 at 7:00 a.m. 08/20/11 at 12:15 a.m., 08/20/11 at 5:35 a.m., 08/20/11 at 10:30 a.m. The PRN [MEDICATION NAME] record indicated Resident A received 4 milligrams of [MEDICATION NAME] on 08/18/11 at 10:50 p.m. A Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] A MAR indicated [REDACTED] A MAR indicated [REDACTED]. A MAR indicated [REDACTED]. On 08/20/11 (date Resident A was sent out to the ER), the MAR indicated [REDACTED]. A 5-day MDS (Minimum Data Set) assessment, dated 08/20/11, indicated Resident A had no cognitive impairment, understood what others said to her, was understood by others, and was on a scheduled pain regime. The MDS indicated Resident A was continent of bowel and bladder. A "Progress Note," dated 08/20/11 at 6:00 a.m., indicated, "(Up) to BR (bathroom) last noc (night) c (with) ii (2) assist. [MEDICATION NAME] given x (times) 2 this shift et has had muscle relaxer. Res (Resident A) states relief. Resting quietly at present time. Pillow between legs et in back of incision....0 (No) c/o (complaints of) voiced. 0 distress noted." A "Progress Note," dated 08/20/11 at 11:00 a.m., indicated Resident A's vital signs were - blood pressure 112/48, heart rate 42, respiratory rate 16. The progress note indicated the resident's oxygen saturation was 88%. The progress note indicated, " (Resident A) awakens easily, but drowsy - unable to follow simple instructions - unable to sit (up) chair (sic) for brkfast (sic). No intake - new patch applied per N.O. (new order.)...13:30 (1:30 p.m.) Incont (Incontinent) of urine - pupils pin pt (point) - slurred mumbling speech - Holding 1400 (2:00 p.m.) meds (medication) too sedative (sic) @ this X (time).....unable to follow any type instructions." A facility "Resident Transfer Form," dated 08/20/11, indicated, " ....Reason for Transfer...Pt unresponsive [MEDICATION NAME] (sic) patch dose (change) MD (Medical Doctor) advised to remove patch @ this time. EMT ' s aware et removed patch. Pt will not open eyes or respond (sic) some drooping of mouth noted." The only time on this form was the time vital signs were taken. The time documented for vital signs taken was 4:30 p.m. The form indicated the resident ' s vital signs at 4:30 p.m. were - blood pressure - 124/60, heart rate - 89, respirations - 20, and temperature 98.4. The form indicated the resident's oxygen saturation at that time was 90% on room air. Interview of the DON (Director of Nursing) on 10/12/11 at 10:00 a.m., indicated Resident A had been having increased pain so the doctor had increased her pain medication. The DON indicated she thought it was on a Saturday when the resident hadn't eaten much and the "PM" nurse came in and noticed the resident was a little lethargic. The DON indicated the PM nurse called the doctor and he told her to hold Resident A's [MEDICATION NAME]. The DON indicated the family came in and were upset due to not being notified of the resident's lethargy. The DON indicated the doctor said the only thing they should have done differently was to remove the resident's [MEDICATION NAME]. The DON indicated she was not aware of whether or not oxygen was started on the resident. A copy of a written report regarding incident with Resident A was provided by the DON on 10/12/11 at 2:20 p.m. This report was written by the ADON. The report indicated, "1531 (3:31 p.m.) (PT #2's name) called me (ADON) at home to notify me of a change in condition on (Resident A)....She reported resident appears sedated which is a change from previous condition. Approx (Approximately) 1540 (3:40 p.m) I (ADON) called facility & spoke with (RN #5) the nurse who had started at 1500 (3:00 p.m.). I informed her to do an assessment and call (doctor's name) with resident condition and request any new orders. The report indicated the ADON received a call from the facility on 08/20/11 at approximately 5:00 p.m., to report that Resident A's family was at the facility and were very upset that they had not been notified of (Resident A's) change in condition. I called and spoke with the resident's (family) who said she wanted (Resident A) transported to ER (emergency room ).....RN #5 informed me that ambulance (sic) was already in route...." A copy of an OT documentation form was provided by the DON on 08/20/11 at 2:20 p.m. The OT documentation form was signed by OT #3. The form indicated, "On Sat (Saturday) 8/20/2011 (Physical Therapy Assistant's name) PTA #4 and (Occupational Therapist name) OT #3....arrived at pts (Resident A's) room (symbol for around) 2:45 p.m. CNA x (times) 2 were performing a bed bath. Pt demo (demonstrated) significant change from previous day. Previous day pt was answering questions and making needs known, on this day pt was unable to answer simple yes/no questions, only moan & groan. Then left pt's room and called Physical Therapy Department Director's name), collaborated briefly with (RN on duty's name) RN #1, and wrote on 24 hour report. Review of a local hospital emergency room report on 10/12/11 at 12:10 p.m., indicated Resident A was on her way to the emergency room from the facility on 08/20/11. The report indicated Resident A arrived at the emergency room (ER) on 08/20/11 at 6:35 p.m. The report indicated, "....(Resident A) has had increase in [MEDICATION NAME] and [MEDICATION NAME] & today has been unresponsive since 11:00. The report indicated Resident A's physician "called & spoke with this RN & states contact EMS (Emergency Medical Service) to remove patch ([MEDICATION NAME]) & have [MEDICATION NAME] (medication frequently used to treat known or suspected opioid-induced respiratory depression). EMS contacted & patch removed. U/A (Upon arrival) pt unresponsive -eyes closed - not speaking. Pt will respond to painful stimuli... - Applied monitor, O2 (oxygen), IV.... " An "Emergency Department Nursing Progress Note," dated 08/20/11 at 6:45 p.m., indicated, "[MEDICATION NAME] given - Pt started jerking & twitching entire body - moaning." An "Emergency Department Nursing Progress Note," dated 08/20/11 at 7:45 p.m., indicated, "Pt cont (continues) to flail & jerk - central line placed.... " An "Emergency Department Triage Report," dated 08/20/11 at 6:44 p.m., indicated, " ....Patient Narrative: Staff at (facility) states (Resident A) had a lumbar dissection 1 wk (week) ago and had pain meds increased yesterday. (Resident A) found unresponsive by staff and shallow resp (respirations) with left side facial drooping." A local hospital physician summary, dated 08/20/11, indicated, "....Patient clinically has improved....I am thinking that patient is alert and awake and denies any complaints....I think we can send her to (Rehabilitation Hospital) for further management.... " A local hospital "history and physical examination ....female with fever, confusion, and a little low pressure and [MEDICAL CONDITION](rapid heart rate) and now with elevated cardiac enzymes and possible [MEDICAL CONDITION].I also think we should keep her in the Intensive Care Unit and refer her to (Rehabilitation Center) some time and go from there.... " This Federal/State deficiency relates to Complaint IN 832. 3.1-48(a)(3)

Based on observation, interview and record review, the facility failed to ensure a resident with frequent falls was provided interventions to prevent future falls from her bed, in that the resident fell from the bed resulting in sutures to her right foot, for 1 of 6 residents reviewed with falls in the sample of 15. Resident # 7 Findings include: On 5/16/11 at 9:00 A.M., the Assistant Director of Nursing indicated Resident # 7 was a recent readmission from the hospital. He indicated Resident # 7 had a recent fall resulting in a laceration to the foot which required 5 sutures. He further indicated Resident # 7 was not interviewable. On 5/18/11 at 3:30 P.M., Resident # 7 was observed to be in a low bed that was against the wall with a thin mat on the other side of the bed. Resident # 7 was observed to have her left leg hanging over the side of the bed. The clinical record for Resident # 7 was reviewed on 5/16/11 at 11:00 A.M. The record indicated Resident # 7 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 3/2/11, indicated Resident #7 had moderate cognitive impairment. Resident #7 required supervision with assist of one with bed mobility, supervision with assist of two for transfers. Resident # 7 had fallen and received an injury since the previous assessment completed within the last 90 days. An Accident/Incident Report, dated 12/15/10 at 5:25 P.M., indicated "...CNA went to pts (patients) room to bring down for eve (evening) meal found pt on floor by the foot of bed was sitting in w/c (wheelchair) with blankets over her prior too (sic). No injury...Immediate action taken to prevent further incidents: Neurochecks started, sent to ER (emergency room ) for change in condition..." An Accident/Incident Report, dated 12/25/10 at 7:00 P.M., indicated "...pt st (stated) "was bending over to pick up piece of paper et (and) slid out of w/c on to floor, denys (sic) hitting head or pain...Immediate action taken to prevent further incidents: reminded pt not to pick things up off floor and to use call light for assistance with ambulation/movement..." An Accident/Incident Report, dated 12/31/10 at 3:00 A.M., indicated "...Heard pt say "help" upon entering pt's room found pt on floor sitting on L (left) side of bed. Pt states that she rolled out of bed...Immediate Action taken to prevent further incidents: Neurochecks, ROM (range of motion), Will attempt low bed..." A care plan, dated 1/5/11 and updated on 2/16/11 and 4/3/11, indicated a problem of "Fall/injury assessment: prevention and management plan of care. Fall/injury risk related to: pain, stiffness, osteoarthritis, unsteady, high blood sugar, low blood sugar, cardiovascular diagnosis, bowel incontinence, bladder incontinence, CVA, hearing increased wax in ears, numb/tingling feet, cardiovascular meds (medications), antidepressant, hx (history) of fall/injury: 12-15-10, 12-25-10 fell out of chair reaching for item on floor, 12-31-10, 2/21/11 out of w/c, 3-12-11 fall, 5-14-11 fall." The interventions included but were not limited to "1-7-11 low bed, reaching device, grab bars, reacher, low bed 1-10-11, 12-15-10 sent to ER confused with cystitis ATB (antibiotic) tx (treatment), 12-25-10 provide reacher device/ dysem under chair." A DCR (daily clinical review) note, dated 2/16/11, no time, indicated "Reviewed current safety plan to ensure POC (plan of care) is appropriate for resident. Resident low bed appropriate at this x (time). Resident cont (continues) with positioning bars x 2 to allow res to help turn self et reposition self as needed. Resident up ad lib in room with walker but needs assist of 1 out of room. Will cont to review as needed." The Nurses Notes, dated 2/21/11 at 7:30 P.M., indicated "Pt fell in room has a small hematoma with abrasion to top of head all other exts (extremities) have good ROM. No c/os of (sic) pain except headache...Pt not sure what happened. Neurochecks initiated...Will have therapy look at w/c for trying modifications." The fall care plan, dated 1/5/11, was updated on 2/21/11 to include the intervention of U/A (urinalysis) C & S (culture and sensitivity), OT (occupational therapy) eval (evaluate) and tx (treat) for w/c modifications add lower shelf in room." The fall care plan, dated 1/5/11, was updated on 2/22/11 to include the intervention of spoke with resident re: alarms; Res (resident) refuses becomes upset. An Accident/Incident Report, dated 3/12/11 at 9:15 A.M., indicated "...Resident in room reached forward to place stuff on shelf. Brakes not locked. Resident slid out of chair fell on buttocks. Resident denies hitting head or any pain...Immediate action taken to prevent further incidents: Head to toe assessment. PT (physical therapy) screen requested, placed on 15 min (minute) checks until further notice..." The fall care plan, dated 1/5/11, was updated on 3/12/11 to include the intervention of .PT screen, 15 min obs (observations) An Accident/Incident Report, dated 5/9/11 at 2130 (9:30 P.M.), indicated "...Resident sitting in w/c looking through clothes et leaned forward and brushed face against box. No injury...Immediate action taken to prevent further incidents: nurse assisted resident in cleaning out closet and organizing clothes..." An Accident/Incident Report, dated 5/14/11 at 0230 (2:30 A.M.), indicated "...Heard trash can knock over et went in rm (room) to find res (resident) on knees on floor holding onto rm mates bed with head nest to trash can. Res alert et responded to name, assisted to sitting position gave glucagon 1 mg IM in R (right) arm et assisted res in drinking 200 cc OJ (orange juice) at 0245 (2:45 A.M.) BS (blood sugar) up to 40 at 0300 (3:00 A.M.) BS 60 et res A&O x (alert and oriented times) 3 denies pain. Lg (large) amt (amount) of blood noted under res coming from R ft (foot) little toe, noted laceration to underneath side of toe scattered bruises to R arm et bruise to R side of chin which res stated was from hitting box on 5/9/11. Bruise- scattered. Laceration- 3 cm....Immediate action taken to prevent further incidents: cleansed toe et applied dry dsg (dressing), notified MD et sent res to ER. Moved bed against wall in low position et applied mat to floor beside bed d/t (due to) res ref (refused) alarms..." The fall care plan, dated 1/5/11, was updated on 5/14/11 to include the intervention of bed next wall, matt (sic) to floor. A Physician order, dated 5/15/11, indicated "Remove sutures R toe on 5/24/11." 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure cognitively impaired residents were provided with appropriate interventions and supervision to prevent falls, in that residents with memory and cognitive impairment were expected to use call lights and wait for care, residents with bed and chair alarms used to alert staff to their arising without assistance could not be reached timely to prevent falls, and alternative interventions were not planned when bed and chair alarms were ineffective in alerting staff to residents' safety needs. The deficient practice affected 3 of 4 residents reviewed related to falls in a sample of 4. Residents N and M sustained fractures. Residents V, N and M Findings include: 1. The clinical record for Resident N was reviewed on 2/3/11 at 11:35 A.M. The record indicated Resident N had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 1/7/11, indicated Resident N had moderately impaired cognition. Resident N required extensive assistance of two with bed mobility and toilet use. Resident N required extensive assistance of one with transfers, and had no falls since admission. A physician order, dated 12/31/10, indicated, "Up with assist x (times) i (one). Pressure alarm to bed and chair R/T (related to) fall risk. Ambulation 1A (one assist). Transfer 1A, Resident supervision- general. Bed alarm." A Care plan, dated 1/1/11, indicated a problem of "Fall/injury risk related to: unsteady, exhaustion, weakness, hearing impairment, visual impairment, use of cardiovascular meds (medications), antidepressant, sedative/hypnotic." The interventions included, but were not limited to, "bed alarm," "1/17/11 neuro checks and bed alarm," and "1/31/11 to ER (emergency room ), fx (fracture) right hip." The Nurses Notes, dated 1/12/11 at 2:30 P.M., indicated, "Alarm sounded. Attempted to get up...non compliant with care. Would not let CNA's assist...." The Nurses Notes, dated 1/15/11 at 2:00 P.M., indicated, "Non compliant with alarms- gets up by herself without calling for assistance...." The Accident/Incident Report, dated 1/17/11 at 12:30 A.M., indicated, "...Alarm sounded CNA found resident on floor. Resident states I was trying to go to bathroom...LOC (level of consciousness): Alert, confused...Does the resident know what caused the incident? yes Reason: trying to go to bathroom...Immediate Action Taken To Prevent Further Incidents: Low bed. Educated resident to use call light...." The DCR (daily clinical review) notes, dated 1/17/11, no time, indicated, "DCR in regards to fall on 1/17/11. Hematoma noted on back of head. Neuro checks initiated et (and) WNL (within normal limits). Low bed added to POC (plan of care)...." The Accident/Incident Report, dated 1/31/11 at 7:00 P.M., indicated, "...pt (patient) was found in floor by bathroom CNA reported alarm was sounding then stopped when CNA reached pt room the pts roommate stated she had turned it off range of motion with in normal limits for pt no bruising or injuries noted c/o (complaints of) R (right) hip pain. pt stated she didn't hit her head. Alert et (and) oriented x (times) 3...Does the resident know what caused the incident? yes Reason: getting up with out help...Immediate action taken to prevent further incidents: Reminded pt to use call light made sure alarm is working et in place also let pts roommate know that in the future she was not to turn off pts alarm but to get staff or turn on call light...." The Nurses Notes, dated 2/1/11 at 9:00 A.M., indicated, "X ray report received of R hip shows impacted Fx (fracture) of the neck of the femur...New orders received to send to ER (emergency room ) for evaluation." The DCR notes, dated 2/1/11, no time, indicated, "DCR in regards to fall on 1/31/11. Assessed per nurse et ROM (range of motion) WNL et no external rotation noted. Xray ordered. Sent ER (emergency room ) for fx (fractured) R (right) hip. admitted to (name) hospital." 2. The clinical record for Resident V was reviewed on 2/3/11 at 11:10 A.M. The record indicated Resident V had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 10/27/10, indicated Resident V had severe cognitive impairment. Resident V required extensive assistance of one with bed mobility, transfers, ambulation, and toilet use. Resident V had fallen since the prior to assessment. A care plan, dated 8/9/10, indicated a problem of "Fall/Injury Risk related to: pain, unsteady, weakness, bowel and bladder incontinence at times, dementia, visual impairments, diuretic, antianxiety, narcotics, history of fall/injury: 8/16/10, 8/30/10, 9/3/10, 10/1/10, 10/12/10, 11/15/10, 11/19/10, 12/10/10, 12/28/10 and 1/29/11." A physician order, dated 8/12/10, indicated, "Pressure alarm to bed and chair- check placement and function every shift." An Accident/Incident Report, dated 8/16/10 at 6:15 P.M., indicated, "...(Resident V) was in her room visiting with her sister in law. She reached over to get something out of her purse and slipped out of w/c to sit on floor. Sister in law also said (Resident V) leaned over and slipped to floor out of w/c...Immediate action taken to prevent further incidents: Inst (instructed) not to lean over. Will request grabber from PT (physical therapy) for her use...." The DCR (daily clinical review) notes, dated 8/16/10, no time, indicated, "DCR in regards to fall 8-16-10. Res was in her rm visiting with family. Res reached over to get something out of her purse and slipped out of w/c to sit on floor. Will request grabber from PT (physical therapy) for her use. C/P (care plan) updated." An Accident/Incident Report, dated 8/30/10 at 6:00 A.M., indicated, "...6 AM resident was sitting in w/c at nurses station had to be told several times to sit down. At 6 AM chair alarm on resident was in room (number) husbands room husband said she slid out of w/c and was on her knees when CNA answered alarm...Immediate action taken to prevent further incidents: Make sure bed and chair alarms are functioning...." The DCR (daily clinical review) notes, dated 8/31/10, no time, indicated, "DCR in regards to fall on 8-30-10. Res was sitting in w/c at nurses station and went to husbands rm (room) to visit. Res alarm sounding and husband said she slid out of w/c and was on knees when CNA answered alarms. No injury noted. CT scan done waiting on results. Med (medication) review completed by Dr. Res will also be taken to husband's rm early am to visit daily. Pain assessment completed and Care plan updated. Continue with POC (plan of care)." An Accident/Incident Report, dated 9/3/10 at 0450 (4:50 A.M.), indicated, "...Resident kept attempting to get up et down out of w/c. Alarm sounds CNAs et RN kept directing took to bathroom back to w/c then tried to get up et slipped out of w/c onto bottom...Immediate action taken to prevent further incident: has alarms continue to monitor wear nonskid socks...." The DCR (daily clinical review) notes, 9/3/10, no time, indicated, "DCR in regards to res had fall on 9/3/10 at 04:50. Res was attempting to get up out of w/c. Alarm sounded CNA and nurse went but res slipped out of w/c on to bottom. Intervention is to put non skid socks on res in eve (evening). Care plan reviewed and updated." An Accident/Incident Report, dated 10/1/10 0540 (5:40 A.M.), indicated, "...Alarm went off by the time we got there appears she climbed over end of recliner et landed on bottom on floor. Denies pain no area noted...Immediate action taken to prevent further incidents: remind to use call light for assistance...." The fall care plan, dated 8/9/10, was updated, on 10/1/10, to include the intervention of "Neurochecks per protocol." The DCR (daily clinical review) notes, dated 10/5/10, no time, indicated, "DCR in regards to fall on 10-1-10. Alarm went off by the time staff got there it appeared she climbed over end of recliner and landed on bottom on floor. Denies pain or injury med review go be done. gripper socks at hs (bedtime) c/p (care plan) revised." The fall care plan, dated 8/9/10, was updated, on 10/10/10, to include the intervention of "moved alarm to other side of bed and under the bed." The DCR (daily clinical review) notes, dated 10/11/10, not timed, indicated, "DCR in regards to fall on 10-10-10. Bathroom alarm sounding. CNA found res on floor. Res stated that she turned bed alarm off. Last time res used call light for toileting when educated on use of call light et (and) bed alarm. Res stated didn't remember. Immediate action moved bed alarm to other side of bed under bed...." An Accident/Incident Report, dated 10/12/10 at 0705 (7:05 A.M.), indicated, "...Res sleeps in recliner with foot rest up. Didn't use call light got up without putting foot rest down and fell alarm sounded but fell back before they could prevent it from occurring...Immediate action taken to prevent further incidents: instructed to use call light and for the CNAs to take her to BR (even if sleeping) when they arrive at 6:00...." The fall care plan, dated 8/9/10, was updated, on 10/12/10, to include the intervention of "Res to be out of bed early in AM." The DCR notes, dated 10/13/10, no time, indicated, "....Res had fall 10/12/10 Res sleeping in recliner with foot rest up did not use call light got up without putting foot rest down and fell alarm sounded but res had fallen before could get there. Interventions was res to be toileted q (every) 2 hrs (hours) and as needed. Care plans reviewed and updated." The fall care plan, dated 8/9/10, was updated, on 10/13/10, to include the intervention of "Toilet q (every) 2 hrs (hours) and as needed." An Accident/Incident Report, dated 11/1/10 at 7:15 P.M., indicated, "...Heard alarm sounding by the time (CNA name) got to her she was sliding to floor...Immediate action taken to prevent further incidents: Toilet resident, offer food and drinks, and placed by nurses station for supervision...." An Accident/Incident Report, dated 11/15/10 at 8:55 P.M., indicated, "...Resident slid out of chair onto Rt (right) side. Resident was trying to pick up newspaper...Immediate action taken to prevent further incidents: Assess wheelchair feet don't touch floor...." The fall care plan, dated 8/9/10, was updated, on 11/15/10, to include the intervention of "OT (occupational therapy) to look at chair cushion. New bag ordered for w/c. Scoop mattress. Low bed." The DCR (daily clinical review) notes, dated 11/17/10, no time, indicated, "DCR in regards to fall on 11-15-10. Res slid out of chair onto R (right) side Res was trying to pick up newspaper. Therapy to assess proper cushion, bag for goodies and position. C/P (care plan) revised." An Accident/Incident Report, dated 11/19/10 at 2215 (10:15 P.M.), indicated, "...Alarm sounded et resident found lying on floor in hall outside of room Hematoma noted on forehead 2 1/2 cm in diameter with swelling noted over L (left) eye. Ice applied et neuro checks initiated...Immediate action taken to prevent further incidents: toileted, fluids and snacks offered...." The DCR notes, dated 11/22/10, no time, indicated, "DCR in regards to res had fall 11/19/10 at 2215 (10:15 P.M.). Res alarm sounded et res found lying on floor in hall outside of room. Hematoma noted on forehead 2 1/2 cm in diameter with swelling noted over lt (left) eye. Ice applied et neuro checks initiated. OT (occupational therapy) to look at seating and discuss safety of chair. Care plan reviewed." An Accident/Incident Report, dated 12/10/10 at 9:15 A.M., indicated, "...Res sitting in w/c- Roho cushion had side forward when res slid forward to get into BS (bedside) table- slid out into floor. Alarm in tact and functioning went off by the time assist got to her she was on the floor...Immediate Action taken to prevent further incidents: Roho cushion removed dysum placed under it and Roho placed correctly...." The fall care plan, dated 8/9/10, was updated on 12/10/10, to include the intervention of "Anti thrush (sic) cushion." An Accident/Incident Report, dated 12/27/10 at 9:45 P.M., indicated, "...CNA was toileting res et turned to put resident's purse down et resident slipped off toilet before CNA could stop the fall...Immediate action taken to prevent further incidents: reminded pt to ask for assistance. When getting up, check alarms to make sure they were in working order reminded pt to use call light while in recliner or bed...." The fall care plan, dated 8/9/10, was updated on 12/28/10, to include the intervention of "non skid socks and pt to ask for help toileting." An Accident/Incident Report, dated 1/29/11 at 1:30 P.M., indicated, "...Pt (patient) was in husbands room sitting in recliner with alarm under her. Foot rest was up. Pt attempting to get up to BR (bath room) et (and) slid to floor. Pt alarm was sounding et found sitting position on floor...Immediate action taken to prevent further incidents: bringing pt down to nurses station after lunch...." The DCR (daily clinical review) notes, dated 1/31/11, no time, indicated, "DCR in regards to fall on 1-29-11 Res (resident) in husbands room sitting in recliner foot rest up alarm on res attempted to get up to bath room slid to floor. Care plan updated." 3. Resident M was observed on 2/3/11 at 12:30 P.M., to have a cast to her left wrist and lower arm and to have an open area above her left eyebrow. RN #1 indicated at this same time the area above her eyebrow was a laceration from a fall. Resident M's clinical record was reviewed on 2/3/11 at 12:00 P.M. The most recent Minimum Data Set (MDS) assessment, dated 11/16/10, indicated the resident was moderately cognitively impaired, with memory loss, required extensive assistance with transfers and ambulation and was frequently incontinent of urine. The assessment indicated the resident had a fall with injury since the last assessment date. The prior assessment, dated 8/25/10, indicated the resident was moderately cognitively impaired, required cues and supervision, had short term memory loss, does not recall after 5 minutes, assistance was required with transfers and ambulation, and had a fall in the past 30 and 31 to 180 days. The MDS assessment, dated 7/1/10, indicated the resident had short term memory loss, was cognitively impaired and required extensive assistance with transfers and ambulation. A current care plan problem, dated 10/09 through 11/12/10, indicated, "Fall/injury assessment: prevention and management care plan. Fall injury risk related to... shuffled gait, unsteadiness, exhaustion, weakness, cognitively impairment factors, sensory impairment factors, visual ...history of falls 6/19/10, 8/23/10, 9/3/10, 9/7/10, 9/28/10, 10/6/10, 10/9/10,10/24/10, 11/7/10, 1/24/11, and 1/31/11." Goals included: "To be free of serious injury, will have a decrease in the number of falls." Interventions included, but were not limited to: "Ambulation 1 assist, transfer 1 assist, non skid adhesive to floor and gripper socks- 9/29/10, bed next to wall-10/6/10, hip guards- 10/9/09, dining room all meals- 10/9/10, enablers-chair alarm and bed alarm- 10/11/10, mat to floor- 10/24/10, 3 day initiated to start toileting plan, moved closer to nurses station- 1/24/11, education provided- 1/31/11." Accident/Incident Reports, included in nurses notes, indicated: "6/19/10 5:30 a.m. found resident on floor. states I was going to the bathroom and fell , immediate interventions were pad alarm to bed and wheelchair at all times for 3 days..." A nurses note entry for 5:30 a.m. on 6/19/10 indicated, "Found resident on floor. states 'I was going to bathroom, I fell and hit my head on the floor...has knot on back of head...new order from Dr...pad alarm to bed and wheelchair at all times for 3 days then re-eval.'" Accident/Incident Reports, dated 8/11/10 at 8:00 A.M., indicated, "Patient found by staff laying on belly over side of bed. Pt states she fell across bed. staff of 2 needed to get sitting up." Accident/Incident Reports, dated 8/23/10, indicated a fall at 5:45 a.m., "Resident alarm on, CNA went to room and resident sitting on floor near bathroom did not use walker-said had to use bathroom." The Daily Clinical Review progress notes, 8/23/10, indicated, "545 a.m. had just given med to resident, was around corner, alarm went off, CNA answered, resident was sitting flat on floor near bathroom, did not use walker...." An Accident/Incident Report, dated 9/3/10 at 6:30 p.m., indicated, "Was in bathroom slipped and fell between commode and sink." Immediate action taken was "instructed on importance of turning on call light as needed for assistance, transferring from commode to sink to wash hands, complaints of pain in right hip." The Daily Clinical Review progress notes, dated 9/4/10, in regard to fall on 9/3/10, indicated, "Res was in bathroom and slipped and fell between commode and sink, complained of pain in hip, sent for x-rays...." A nurses note entry, dated 9/4/10 at 1 a.m. indicated the "resident was educated on use of call light, low bed in place and pad alarm (sounds when weight off pad) on and in place." An Accident/Incident Report, dated 9/7/10 at 7:00 P.M., indicated, "In bathroom slid down wall with her back, said she turned and lost balance, was ambulating, transferring from commode to sink to wash her hands. Immediate intervention indicated 2 bed alarms in bed as she will be laying sitting on one at all times. Was transferring commode to sink to wash hands." The Daily Clinical Review progress notes, dated 9/8/10, indicated, "Review of falls 9/7/10, resident alarm was not sounding due to resident was sitting on her bed below the alarm pressure pad." An Accident/Incident Report, dated 9/28/10 at 7:50 a.m., indicated, "Alarm sounding CNA entered room, resident sitting on floor between bed and bathroom, states "'I'm ok,' reminded resident of need for assist when getting up." A nurses note entry dated 9/29/10 at 10:20 a.m. indicated, "patient states feeling sore all over from fall...." The Daily Clinical Review progress notes indicated, "9/28/10 in regards to fall on 9/28/10 at 7:50 a.m. Res alarm sounding CNA entered room Res sitting on floor between bed and bathroom states I'm OK. Reminded res of need for assistance when getting up...." The Accident/Incident Report, dated 10/6/10 at 3:30 p.m., indicated, "Found laying (sic) on left side, laying (sic) on floor by CNA." Immediate action: "encouraged not to shut alarm off, bed was moved next to wall to allow for slower time to get up." The form indicated the fall occurred when resident was" transferring from bed to toilet." The Daily Clinical Review progress note, dated 10/7/10, indicated, "Follow up fall 10/6/10, neuro checks initiated, plan of care updated...." An Accident/Incident Report dated 10/9/10 at 6:00 p.m. indicated, "(Resident name) wheeled down the hall then stood up out of her wheelchair and fell on her side. alarm sounded. Nurse and CNA there just after she fell ." Immediate actions taken were "keeping resident by nurses station and one one one until bedtime." The Daily Clinical Review progress notes, dated 10/11/10, indicated, "...fall on 10/9/10 res wheelchair down the hall when stood up out of her wheelchair fell on her side, alarm was sounding immediate interventions keeping res by nurses station as much as possible and one on one until bedtime...." An Accident/Incident Report, dated 10/24/10 at 1:50 p.m., indicated, "Alarm sounded CNA and nurse immediately respond and pt. was on her knees on side of her bed." Immediate action taken were: "low bed, mat to floor." A nurses note entry, dated 10/24/10 at 2:00 p.m. indicated, "Pt was found on hands/knees in floor next to bed, which was in low position. Pt could not tell us why she was trying to get up. Toileted before going to bed at 1:15 p.m. Alarms in place and functioning at time. Call light was in reach...." An Accident/Incident Report , dated 11/7/10 at 2:30 P.M., indicated, "CNA heard alarm sounding went to room and caught patient standing up. CNA lowered pt down to floor and sat on blue mat next to bed." Immediate interventions were "sit at nurses station to be watched more closely." "yes resident was trying to get to toilet." A nurses note, dated 11/7/10, indicated, "pt was lowered to floor by CNA after CNA heard alarm sounding went to room and was able to catch patient...." The Daily Clinical Review progress notes, dated 11/18/10, indicated: "CNA heard alarm sounding went to room and caught pt standing up CNA lowered pt down to floor and sat on blue mat next to bed...." The Accident/Incident Report, dated 1/24/11 at 5:30 A.M., indicated, "Heard alarm went to answer alarm, found res on floor, face on floor, left side turned patient over, sustained 2 cm laceration on left eyebrow, 3 cm by 3 cm abrasion left elbow, red shoulder left and left hand." Immediate interventions were "talk to res to use call light, put her near nurses station at 7 P.M. take to toilet every 2 hours." The Emergency Discharge note from the hospital, dated 1/24/11, indicated, "Fracture of left radial styloid (wrist) chip fracture of dorsal triquetrum (wrist), laceration - leave steristrips in place for 8 to 10 days." The Daily Clinical Review progress note, dated 1/24/11 indicated, "Fall 1/24/11. Res found on left side on floor alarm was sounding. Res received laceration left eyebrow and abrasions left elbow....an entry dated 1/25/11 fracture left hand times 2. Moved res closer to nurses station...." A nurse's note, dated 1/24/11 at 9:30 p.m., indicated the resident returned to facility from local hospital with immobilizer on left wrist, fracture of left wrist. Resident was moved to a room closer to the nurses station due to "non compliance of using the call light for assistance." An Accident/Incident Report dated 1/31/11, at 5:15 a.m., "indicated, resident up from toilet and fell in room, hit head." Immediate intervention indicated, "Educated CNA not to leave resident in bathroom alone." The Daily Clinical Review progress notes, dated 1/31/11, indicated: "Fall 1/31/11. Resident transferring from toilet to bed and fell . Hit back of head with no apparent injury noted...." During interview with the Director of Nursing (DoN) on 2/3/11 at 1:00 P.M., she indicated CNA #1 had left the resident alone in the bathroom unattended with no alarms and she fell . CNA #1 was still on orientation with the facility and was inserviced not to leave residents alone who require safety measures. The DoN further indicated she was aware there was a problem with falls at the facility and was working on the issue but had only been at the facility for a few weeks. This federal tag relates to Complaint IN 540. 3.1-45(a)(2)