Every finding on record at Edgewater, A Wesleylife Community

Based on clinical record review, facility document review, resident interview, staff interviews, safety data sheets, and policy review, the facility failed to ensure a continuous positive airway pressure (CPAP) machine (device used to keep airway open during sleep) was filled with the correct solution for 1 of 2 residents reviewed (Resident #14) for CPAP use. Staff filled Resident #14's CPAP machine with distilled vinegar (acedic acid) instead of distilled water resulting in the resident complaining of a headache, burning eyes and altered taste. The facility reported a census of 36. Findings include: The Minimum Data Set (MDS) Assessment completed on 7/18/26 revealed Resident #14 admitted to the facility on [DATE]. A Brief Interview for Mental Status score of 15/15, indicating intact cognition, was noted. Diagnoses include chronic obstructive pulmonary disease, heart failure, obstructive sleep apnea, pulmonary hypertension (high blood pressure in the lung's arteries), and respiratory failure. The MDS reported the use of a non-invasive mechanical ventilator (breathing machine). The Order Summary Report for Resident #14, obtained on 7/30/26, showed the following nursing order: Apply CPAP as directed; On in evening and off in morning; Use personal machine. The order was initiated on 7/15/26. The Grievance Investigation form dated 7/16/26 outlined Resident #14 reporting a nurse put vinegar in the CPAP machine. The allegation was validated by the Director of Nursing (DON) and identified Staff D, Registered Nurse (RN), as the nurse involved. During an observation of the supply room on 7/29/26 at 11:30 AM, jugs of distilled water and distilled vinegar were stored on a bottom shelf right next to each other. Both solutions were clear and in similar 1-gallon plastic transparent jugs. The DON was present in the room and noted Staff D had grabbed the incorrect jug to fill the CPAP machine.The Nurse's Note from 7/15/26 at 11:59 PM documented Resident #14 was admitted for respiratory and heart failure follow-up. The resident adjusting fine with no concerns raised. The Skilled Evaluation note from 7/16/26 at 7:39 AM, completed by a nurse, documented pain to the right- and left-hand palms and to the right and left foot. Pain rated a 3 out of 10 (mild) and noted to occur multiple times during the day. No documentation noted regarding Resident #14 respiratory status or any further discomfort.The Administration Note from 7/16/26 at 9:32 AM documented a pain reliever, acetaminophen, was given. The resident stated the night nurse put vinegar in my CPAP and now has a headache. The Nurse's Note from 7/16/26 at 11:25 AM documented the resident alerted staff in the morning there was vinegar in the CPAP water chamber instead of distilled water. Nursing staff immediately turned off the CPAP and the machine was cleaned. The resident denied coughing or an irritated throat. The resident complained of a headache they had prior to noticing the vinegar. The Medication Administration Record (MAR) for July 2026 documented as needed acetaminophen was administered to Resident #14 on 7/16 at 9:32 AM. The resident rated their pain at a 5 out of ten (moderately strong). The MAR did not show the resident receiving as needed acetaminophen at any time on 7/14/26 or 7/15/26. Resident #14 received scheduled acetaminophen, as per physician order, at 6:00 PM on 7/15/26 and at 12:00 AM, 6:00 AM, and 12:00 PM on 7/16/26. The midnight and 6AM doses were administered by Staff D. During an interview on 7/27/26 at 11:30 AM, Resident #14 reported a night nurse filling their CPAP machine with vinegar. The resident explained they could not smell the vinegar as their sense of smell was affected by a previous Covid diagnosis. They recalled developing a headache and taste changes after wearing the CPAP mask all night. The machine utilized was a ResMed AirSense 11, which the resident brought with them and was not facility issued. During an interview on 7/29/26 at 8:30 AM, Staff E, Certified Nursing Assistant (CNA), explained they noticed a vinegar odor just outside of Resident #14's room the morning of 7/16/26. Upon entering the room, the resident was still wearing the CPAP mask and a jug of vinegar sitting on the bedside dresser. Staff E recalled Resident #14 complained of a headache, burning eyes, and a vinegar taste in their mouth. The nurse was notified and the CPAP parts were rinsed out. During an interview on 7/29/26 at 9:25 AM, Staff F, Licensed Practical Nurse (LPN), acknowledged they were the nurse who responded to the CNA's call about the vinegar. Upon arrival to the room, Staff F recalled noticing a faint vinegar odor. When the CPAP water reservoir was opened, Staff F confirmed vinegar was present instead of water. The jug of vinegar was still at bedside. Resident #14 voiced having a headache but noted it was better then before. Staff F recalled the resident developing more of a headache later. No further breathing issues identified during the rest of their shift. During an interview on 7/29/26 at 10:00 AM, the Medical Director explained respiratory issues, such as wheezing, shortness of breath, would be their main concern if inhaling vinegar via a CPAP machine. They would expect staff to escalate medical care as needed based on resident symptoms. During an interview on 7/29/26 at 11:55 AM, Staff G, Respiratory Therapist with a medical equipment supply company, noted vinegar should not be used to fill a CPAP machine due to its acidic nature. Short term effects of inhaling vinegar may include burning and/or coughing. A physician should be consulted if concerned about possible long term effects. During an interview on 8/3/26, at 9:25 AM, Staff D, acknowledged filling the CPAP reservoir with vinegar. The night of 7/15/26, Staff D noted the CPAP water reservoir was not completely full and elected to fill it up. Staff D had worked with CPAP machines in the past and knew to fill with distilled water. When in the supply room, Staff D explained there were no jugs of distilled water. However there were jugs of distilled vinegar right next to the water. Staff D believed the distilled vinegar was an appropriate substitution given the term distilled on the label. Once in the resident's room, Staff D showed the jug to Resident #14 and they both noted the term distilled on the label. Staff D voiced this should be fine and the resident agreed. Staff then topped off the water reservoir with vinegar. Staff D estimate pouring 40 milliliters (approximately 3 tablespoons) of vinegar. The reservoir holds approximately 380 milliliters of fluid (approximately 1.5 cups). Staff D explained not smelling the vinegar as it was mixed with the water. The CPAP machine did not need to be refilled during the night. Staff D reported Resident #14 did not voice any complaints during the night or when the scheduled acetaminophen was given at 6:00 AM. The Material Safety Data Sheet (MSDS) for distilled vinegar, provided by the facilty, noted prolonged inhalation of vapors can cause irritation to the respiratory tract. First aid includes removal to fresh air and supportive breathing (give oxygen). Eye exposure may cause burning and redness. The user guide for the ResMed Airsense-11 CPAP machine noted the following directions: 1. Open the humidifier tub and fill it with water a. If the machine has a standard water tub, only use distilled water. b. If the machine has a cleanable water tub, drinking water may be used 2. Fill the water tub to the maximum water level mark. The tub has a maximum capacity of 380 millilitersInstructions to clean the CPAP machine, as outlined in the user guide: 1. Cleaning the humidifier tub weekly with a mild dishwashing liquid OR a solution with a ratio of 1 part vinegar and 9 parts water 2. To remove any white powder deposits, use a solution of 1 part household vinegar to 10 parts water; Rinse clean with waterThe undated staff competency checklist titled Continuous Positive Airway Pressure (CPAP) noted the use of distilled water for the machine. A solution of 1 part vinegar and 2 parts water may be used weekly to clean water build-up in the chamber.

Based on clinical record review, staff interviews and policy review the facility failed to notify the physician in a timely manner when the resident had a significant change in weight for 1 of 3 residents reviewed (Resident #11). The facility reported a census of 36 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had diagnoses of heart disease, atrial fibrillation (irregular heart beat), fluid overload and lymphedema (swelling caused by a buildup of fluid due to the lymphatic system is blocked or damaged). The MDS recorded the resident took a diuretic (water pill) and used oxygen. The Care Plan revised 11/14/25 revealed the resident had altered cardiovascular status related to atrial fibrillation and coronary artery disease, and took a diuretic due to fluid volume overload. The Care Plan directed staff to monitor, document and report any changes in weight or edema. The Medication Administration Record (MAR) revealed the following orders: a. Check weight weekly. Notify the provider if the resident had a gain of 5 lbs (pounds) or more in that weekly interval. The order began on 12/7/25. b. Bumetanide (a diuretic) (water pill) 2 milligrams (mg) every day (qd) for fluid overload started on 10/3/25. The Electronic Health Record Weights and Vitals section revealed the following: 5/17/26 214.8 lbs5/24/26 214.0 lbs5/31/26 212.4 lbs 6/5/26 222.4 lbs (a 10 lb weight gain)6/14/26 225.4 lbs6/21/26 224.2 lbs6/28/26 225.4 lbs7/5/26 220.0 lbs7/19/26 221.6 lbs (last recorded weight in the resident's record) Weights recorded on the Medication Administration Record (MAR) revealed the following: 5/24/26 214.0 lbs5/31/26 212.4 lbs6/7/26 222.4 lbs (a 10 lbs weight gain since 5/31/26) 6/14/26 225.4 lbs7/5/26 220.0 lbs7/12/26 -area was left blank 7/19/26 221.6 lbsNo weight were recorded on 7/26/26 or 7/27/26 on the MAR. A Communication to the Physician from the dietician that was signed by the physician on 7/8/26, revealed the resident's weight was 225.4 lbs. This was a 13 lb. weight gain (6% increase) in one month. The Progress Notes revealed the following: A Provider Encounter Note dated 6/26/26 at 12:00 AM revealed the resident's weight 224.2 lbs and included a warning there was a 5.0 % weight increase since 6/21/26. An Order Administration Note dated 7/26/26 at 5:29 PM revealed weekly weight not obtained. The resident to be weighed on 7/27/26. The record lacked documentation of a weight obtained on 7/12/26, 7/26/26 and 7/27/26. The record lacked communication to the physician when the resident had a 10 lb weight gain between dates 5/31/2026 to 6/5/2026, and successive weight increase from 6/5/26 to 7/17/26. Observations revealed : a. On 7/28/26 at 10:21 AM Resident #11 sat in a broda chair in his room as Staff H, Licensed Practical Nurse, applied ace wrap dressings to the resident's right and left foot and lower extremities. Resident #11 had swelling in his feet and lower legs.b. On 7/30/26 at 9:45 AM, Resident #11 continued to have swelling and edema in his feet and lower legs. In an interview on 7/29/26 at 10:00 AM, the Medical Director reported he expected staff to notify him when a resident had a 10 lbs. weight gain in a week or worsening of edema. In an interview on 7/30/26 at 9:20 AM, the Director of Nursing (DON) reported she expected staff to follow the physician's orders and notify the provider if a resident had a significant weight gain such as 10 lbs. in a week. On 7/30/26 at 9:30 AM, the DON stated she would review Resident #11's chart to see if she could find any documentation regarding notification to the physician when the resident had a 10 lbs weight gain. In an interview 7/30/26 at 2:15 PM, the DON reported she did not find any documentation regarding notification to the physician when the resident had a 10 lbs weight gain except the communication from the dietician (in July). A Change In Condition-Physician Notification Policy effective 12/2024 revealed the attending physician, nurse practitioner (NP) or on-call provider are notified of changes in condition or heath status. Prompt communication with the Physician and NP are essential to the continuity of resident care and well-being.

Based on clinical record review, observations, staff interviews and policy review the facility staff failed to ensure proper footwear worn by residents during a transfer for 2 of 4 residents observed for transfers (Resident #20 and #23). The facility reported a census of 36 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had diagnoses of Alzheimer's Disease and dementia. The resident had a Brief Interview for Mental Status (BIMS) score of one, indicating severely impaired cognition. The resident also exhibited inattention and disorganized thinking. The MDS revealed the resident had dependence on staff for transfers. The Care Plan revised 6/12/26 revealed Resident #20 had a self-care deficit in activities of daily living (ADL's) related to Alzheimer's Disease. The Care Plan also recorded the resident had a risk for falls due to poor safety awareness and balance problems. The Care Plan directed staff to use two staff and a stand pivot transfer to the wheelchair for transfers and toileting. The Care Plan lacked information regarding use of appropriate footwear. During observation on 7/27/26 at 12:27 PM, Resident #20 sat on the toilet sideways with her left buttock hung over the edge of the toilet seat. No gaitbelt observed on the resident. Resident #20 had thin white socks on her feet. At 12:28 PM, Staff B, certified medication aide (CMA), obtained a gait belt from a hook just outside the bathroom door, and then applied the gait belt around the resident while she sat on the toilet. At 12:30 PM, Staff B instructed the resident to hold onto the bar by the wall and stand up. Staff C, certified nursing assistant (CNA), took disposable wipes, provided pericare and donned a clean brief and pants on the resident. Staff B and Staff C positioned a high back wheelchair and transferred the resident without shoes or appropriate footwear on. At 12:32 PM, Staff B and Staff C then transferred the resident from the wheelchair to the recliner and removed the gait belt.In an interview on 7/28/26 at 1:40 PM, Staff B, reported a gait belt always used for transfers unless a resident used a battery-operated mechanical lift such as a stand lift. Staff B reported Resident #20 was fidgety so staff took the gait belt off while the resident sat on the toilet. 2. The MDS assessment dated [DATE] revealed Resident #23 had diagnoses of Parkinson's Disease, dementia, orthostatic hypotension (a sudden drop in blood pressure that happens when a person stood up after sitting or lying down, leading to lightheadedness, dizziness, and sometimes fainting), and muscle weakness. The resident had a BIMS of 1, indicating severely impaired cognition. The MDS recorded the resident had dependence on staff for toileting and transfers. The MDS also documented the resident had two or more falls without injury since admission.The Care Plan revised 6/18/26 revealed the resident had an ADL self-care deficit and had a risk for falls related to gait and balance problems, Parkinson's Disease, orthostatic hypotension and potential medication side effects. The Care Plan directed staff to use a sit to stand lift and assistance of two staff for transfers.During observation on 7/27/26 at 12:37 PM, Staff B, CMA, placed Resident #23's feet on the hard platform of a mechanical stand lift. Resident #23 had socks (not gripper socks) on his feet. Staff B and Staff C, CNA, placed a sling behind the resident as he sat in a portable recliner chair, attached the sling straps to the mechanical stand lift and transferred the resident from the chair to the bathroom. No strap was placed around the resident's legs. Staff removed the resident's shorts and brief, then lowered the resident onto the toilet. At 12:43 PM, Staff B, raised the resident up in the stand mechanical lift. Staff C took disposable wipes and cleansed the resident's buttocks. Staff C changed her gloves and placed a clean brief and shorts on the resident. Staff B and Staff C transferred the resident from the bathroom to a portable recliner chair, then removed the sling from the lift.In an interview on 7/30/26 at 9:20 AM, the Director of Nursing reported gripper socks or shoes is the appropriate footwear needed when staff transferred a resident. A Safe Resident Transfer and Positioning Procedure effective 5/2026 revealed it is the goal of the facility to reduce the potential for injury for residents and team members through safe transferring and/or lifting. It is expected that the safe resident transfer and positioning procedure be followed at all times. An undated competency titled Transfer a Resident with a Gait Belt revealed under Step 8 to assist the resident in putting on appropriate non-skid footwear. An undated competency titled Transfer a Person Using a Stand Lift revealed under Step 3 to assure the person is wearing appropriate attire for the procedure, including nonskid footwear.

Based on clinical record review, observation, staff interview and review of the facility's incontinence care competency the facility staff failed to provide complete incontinence care for one of three residents observed for incontinence care (Resident #35). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had diagnoses of Parkinson's Disease, cancer and weakness. The MDS recorded the resident had a Brief Interview for Mental Status score of 0 out of 15 indicated severely impaired cognition. The MDS indicated the resident had bladder and bowel incontinence and had dependence on staff for toileting and dressing. The Care Plan revised 7/23/26 revealed Resident #35 had a deficit in ADL's (activities of daily living) related to Parkinson's Disease, and had bladder and bowel incontinence. The Care Plan directed staff to check and change the resident as needed, and wash, rinse and dry the perineum. The Care Plan also revealed the resident had an alteration in skin integrity related to decreased mobility, incontinence and a history of MASD (moisture associated skin damage). The Progress Notes dated 7/24/26 at 9:43 AM revealed the resident had MASD and incontinence associated dermatitis with skin damage to the right intergluteal cleft that measured 1.71 centimeters (cm) by 2.57 cm by 0 cm. During observation on 7/28/26 at 12:50 PM, Staff A, certified nursing assistant (CNA) and Staff B, certified medication aide (CMA) transferred Resident #35 from a broda chair to the bed. Staff A and Staff B donned a pair of gloves and removed the resident's pants and brief. The brief inside was soiled and had a smear of blood. Staff A took one disposable wipe and cleansed between the resident's buttocks. The buttocks area had redness and a small open area present. Staff B applied a clean brief and pulled the resident's pants up.In an interview on 7/30/26 at 9:20 AM, the Director of Nursing reported she expected staff to cleanse all areas whenever incontinence care provided. A Perineal Care/ Incontinence Care Competency revealed the following procedural steps: a. Perform hand hygiene and don glovesb. Remove soiled items. c. Change gloves and perform hand hygiene. d. For Men: wash the penis and scrotum to the upper thighs. e. Turn resident on side. f. Wash the anal area front to back.g Wash the buttocks and upper thighs. Use a fresh disposable wipe with each stroke. h. Change gloves, sanitize hands. i. Apply moisture barrier cream as directed. j. Apply clean clothing (brief).

Based on clinical record review, policy review, family, and staff interviews, the facility failed to provide timely physician and family notifications for 1 of 4 residents (Residents #1) who experienced a change in condition or treatment. The facility reported a census of 39 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS listed Resident #1 as independent with eating. She required moderate assistance with sit-to-stand, chair-to-chair, and toilet transfers. In addition, she required supervision with all other activities of daily living (ADLs) and mobility. The MDS included diagnoses of atrial fibrillation (AFib - irregular heart rhythm), a stroke, traumatic brain injury, and a narrowed heart valve that restricts blood flow through the heart. Resident #1 received a diuretic (a medication that increases urine output to remove salt and water from the body) during the 7-day lookback period.The hospital's Physician Discharge summary dated [DATE] indicated Resident #1 received a diuretic during hospitalization. The order directed to start 7/12/25 until 8/11/25 at 11:59 PM, normal paused since that day until manually restarted.The pharmacy's Request for Clarification admission Orders signed by the physician on 7/14/25 reflected the admitting physician discontinued Resident #1's diuretic.The Nurses' Note dated 7/14/25 at 3:37 PM indicated the facility received clarification from the provider to discontinue the as needed (PRN) diuretic.Resident #1's clinical lacked notification provided to the family of the discontinued diuretic.The Care Plan dated 7/14/23 lacked directives to notify the family or provider of anything other than abnormal labs to the medical doctor (MD).The Summary of Daily Skilled Services dated 7/17/25 reflected Resident #1 had 3+ edema from her left arm from her elbow to her hand.The Plan of Care Note dated 7/21/25 at 1:33 PM indicated the facility had a Care Conference. The meeting included the facility's representatives, Resident #1 and her representatives. The Occupational Therapist reported edema in Resident #1's arms that made it more difficult for her to perform her ADLs. The Director of Nursing (DON) reviewed Resident #1's weights, medications, and answered questions her and her family.The Progress Notes lacked notification to the provider of Resident #1's edema until 7/22/26. The note didn't include Resident #1 had difficulty accomplishing her ADLs.The N Adv Skilled Evaluation dated 7/23/25 at 9:18 AM reflected Resident #1 informed her daughter that she would like her children to all come see her and she would like to hear the voice of Jesus.The Progress Notes lacked notification to the provider about Resident #1's request to her daughter or her change in behavior. On 2/4/26 at 3:01 PM, Staff A, Registered Nurse (RN), stated whoever processed a medication change should notify the resident's family or representative. In addition, she explained they should document the communication in the nurse's notes (progress notes). Staff A reported if a resident suddenly requested family to come see them and made a new comment about heaven, it would constitute a change of condition. At that time, they should notify the provider. She added the staff should document it in the resident's progress notes.On 2/5/26 at 6:24 AM, Staff B, Licensed Practical Nurse (LPN), explained whoever processed the medication change orders should notify the resident's family or representative and document the communication in the nurse's notes. Staff B added if a resident requested family to come see them and made a new comment about heaven, the staff should ask the resident more questions. If the resident never made those type of comments before, it would be a change of condition. Staff B explained they would base notifying the provider on further mental assessment. She reported the resident's progress notes would have the provider communication.On 2/5/26 at 11:09 AM, Staff C, RN, stated the nurse who received the order to change the medication should notify the resident's family or representative. Then they should document the communication in the progress notes.On 2/5/26 at 2:38 PM, the Director of Rehabilitation Services (Rehab Director) stated they expected the nursing department to contact the physician with changes in condition.On 2/5/26 at 4:53 PM, Staff C confirmed she couldn't locate documentation indicating the facility notified the provider.On 2/10/26 at 12:03 PM, the DON reported the staff should notify the family and physician for any change of condition in a resident and document it in the progress notes.The Change of Condition - Physician Notification policy effective December 2024 directed prompt communication with the Physician and Nurse Practitioners are essential to the continuity of resident care and well-being. Communication of the following changes are necessary to determine course of treatment.1. Results in an injury that has the potential for physician intervention.a. Acute symptoms (list is not inclusive-examples only):b. Change in vital signsc. Other conditions as deemed necessary2. Notify charge nurse or supervisor.3. Document time of call, name of the provider spoken to; reason for call and result or orders received.4. Update the resident's care plan to address the change; include new or additional problem (if applicable), goal and approaches. The Change of Condition - Resident Family/Responsible Party Notification policy effective February 2025 instructed to notify the family and/or responsible party of any change in the resident's condition or plan of care. The policy directed staff to document in the resident's medical record, the time called, the person spoken with, what was reported, and their response, if any.

Based on clinical record review, staff interviews, and policy review, the facility failed to personalize 1 of 4 residents' Care Plan (Resident #1) by failing to include their use of diuretic medication therapy. The facility reported a census of 39 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS listed Resident #1 as independent with eating. She required moderate assistance with sit-to-stand, chair-to-chair, and toilet transfers. In addition, she required supervision with all other activities of daily living (ADLs) and mobility. The MDS included diagnoses of atrial fibrillation (AFib - irregular heart rhythm), a stroke, traumatic brain injury, and a narrowed heart valve that restricts blood flow through the heart. Resident #1 received a diuretic (a medication that increases urine output to remove salt and water from the body) during the 7-day lookback period.The hospital's Physician Discharge summary dated [DATE] indicated Resident #1 received a diuretic during hospitalization. The order directed to start 7/12/25 until 8/11/25 at 11:59 PM, normal paused since that day until manually restarted.The pharmacy's Request for Clarification admission Orders signed by the physician on 7/14/25 reflected the admitting physician discontinued Resident #1's diuretic.The Nurses Note dated 7/21/25 at 1:30 PM, Staff E, Registered Nurse (RN), documented the staff monitored Resident #1 for increased edema to bilateral lower extremities (BLE). In addition, Staff E documented the notified the provider of Resident #1's complaint of shortness of breath with exertion and phlegm in back of her throat.The Nurses Note dated 7/22/25 at 6:42 PM, Staff C, RN, documented receipt of new diuretic medication orders due to Resident #1's increased weight and edema.The Care Plan revised 8/6/25 lacked Resident #1's diuretic medication therapy nor provided staff with directions what to monitor or when to intervene.On 2/4/26 at 3:15 PM, Staff A, RN, stated the Care Plan should include a change in the resident's treatment within 48 hours of initiation.On 2/5/26 at 6:41 AM, Staff B, Licensed Practical Nurse (LPN), stated the Care Plan should include a change in the resident's treatment within 24 hours of the change.On 2/5/26 at 11:25 AM, Staff C stated the Care Plan should include the change in the resident's treatment within 24 hours of initiation.On 2/10/26 at 12:03 PM, the Director of Nursing (DON) stated any nurse could update the Care Plan, but the facility designated the MDS Coordinator to manage medication updates.The Comprehensive Care Plan Process revised December 2025 directed the Comprehensive Care Plan must describe the services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on clinical record review, policy review, family, and staff interviews, the facility failed to provide assessments and interventions for 1 of 4 residents (#1). The facility reported a census of 39 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS listed Resident #1 as independent with eating. She required moderate assistance with sit-to-stand, chair-to-chair, and toilet transfers. In addition, she required supervision with all other activities of daily living (ADLs) and mobility. The MDS included diagnoses of atrial fibrillation (AFib - irregular heart rhythm), a stroke, traumatic brain injury, and a narrowed heart valve that restricts blood flow through the heart. Resident #1 received a diuretic (a medication that increases urine output to remove salt and water from the body) during the 7-day lookback period.The Summary of Daily Skilled Services dated 7/17/25 reflected Resident #1 had 3+ edema from her left arm from her elbow to her hand.The facility's Physician Notification Fax dated 7/19/25 indicated Resident #1 had a history of congestive heart failure (CHF).The Nurses Note dated 7/21/25 at 1:30 PM, Staff E, Registered Nurse (RN), documented the staff monitored Resident #1 for increased edema to bilateral lower extremities (BLE). In addition, Staff E documented the notified the provider of Resident #1's complaint of shortness of breath with exertion and phlegm in back of her throat.The Plan of Care Note dated 7/21/25 at 1:33 PM indicated the facility had a Care Conference. The meeting included the facility's representatives, Resident #1 and her representatives. The Occupational Therapist reported edema in Resident #1's arms that made it more difficult for her to perform her ADLs. The Director of Nursing (DON) reviewed Resident #1's weights, medications, and answered questions her and her family.The Nurses Note dated 7/22/25 at 6:42 PM, Staff C, RN, documented receipt of new diuretic medication orders due to Resident #1's increased weight and edema.The N Adv Skilled Evaluation Note dated 7/23/25 at 9:18 AM, Staff F, Licensed Practical Nurse (LPN), documented Resident #1's respiratory assessment. The assessment reflected Resident #1 had diminished (difficult to hear breath sounds) lower lung sounds when listened from the resident's back but indicated she didn't have difficulty breathing or shortness of breath.The Nurses' Note dated 7/29/25 at 9:21 AM, Staff C documented about the family's concern with Resident #1's breathing. Staff C's assessment indicated Resident #1 had audible (loud) wheezing (a high-pitched sound caused by decreased space) noted in her lungs, fluid buildup in her forearms, and a 2-pound (lb.) weight increase from the preceding day. In addition, Staff C documented they contacted the provider because the family requested a change to Resident #1's diuretic due to increased effectiveness.The Nurses Note 7/29/25 at 11:42 AM, the provider changed Resident #1's diuretic per the family's request.The Nurses Note dated 7/30/25 at 3:58 AM, Staff G, RN, documented Resident #1 continued to have respiratory wheezing but denied shortness of breath.Resident #1's clinical record lacked assessments of her lung sounds following 7/30/25.On 2/4/26 at 11:13 AM, Staff C stated staff assess daily weights, lung status, edema, and breathing for residents with CHF.On 2/5/26 at 6:30 AM, Staff B, LPN, explained the staff assess weight, lung sounds, and edema for residents with CHF.On 2/5/26 at 11:45 AM, Staff H, RN, stated the staff assess weight, lung sounds, congestion, edema, and shortness of breath for residents with CHF.On 2/10/26 at 12:03 PM, the Director of Nursing (DON) stated staff should include any change of condition on the hot sheets for nursing follow-up.The Change of Condition Monitoring Process policy effective February 2025 defined a condition change as an alteration from normal status. A significant change in resident status refers to observed changes in the resident's condition warranting immediate nurse assessment, intervention, and appropriate documentation in the clinical record. Physician notification and follow-up is necessary. It included a physical decline in the resident's condition.

Based on clinical record review, facility document review, staff interview, and policy review, the facility failed to provide adequate nursing supervision to prevent a resident from exiting the facility into a patio area without staff's knowledge for 1 of 4 residents reviewed. The facility reported a census of 39.Findings include:The Minimum Data Set (MDS) for Resident #1 dated 8/11/25 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, dementia, Parkinson's disease, and encephalopathy. It also indicated the resident required setup assistance with eating, moderate assistance with oral hygiene, showering, dressing, and personal hygiene, maximal assistance with toileting hygiene and footwear, and supervision with all forms of mobility. It also revealed the resident wandered 1 to 3 days in the seven (7) day lookback period.A Progress Note dated 8/14/25 indicated the resident went outside the facility, knocked on the window, and waved to the on-duty nurse. It also indicated the nurse ran outside to assist the resident back into the facility. It also revealed the resident's wander management system (device used to protect at-risk residents from wandering into unsafe areas) was in place and activated the door alarm upon reentry into the facility.The Electronic Health Record (EHR) included a physician's order dated 8/14/25 for staff to monitor pendant for function and placement daily.The Care Plan dated 8/14/25 included the resident was an elopement risk/wanderer related to Impaired safety awareness and directed staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. The facility also re-initiated a new wander management system device and staff were directed to check it daily to be sure it was functioning properly. The Care Plan had no other dated wandering entries.A Facility Self-Report dated 8/15/25 indicated the resident was brought back inside the facility within one (1) minute per video footage.On 10/16/25 at 10:45 AM, Staff A, Certified Nurse Aide (CNA) demonstrated the proper functioning of the long-term care door alarms.On 10/16/25 at 11:29 AM, Staff B, Licensed Practical Nurse (LPN) stated the resident was fully clothed in street clothes. She stated she saw him a few minutes before he exited the facility and redirected him to his room. She added he was outside for a very short period of time and estimated maybe 3-5 minutes. She also stated the residents do not get the door code and Resident #1 exited through an unalarmed patio door that typically remains locked but had not been relocked after another family used it. She stated the previous requirement was for staff to check the patio doors during their shift and at that time, she had not done that task yet. She said since the event, staff must check the patio and exit doors at the beginning of and during each shift to ensure they are locked and secure.On 10/16/25 at 12:53 PM, Staff C, LPN, stated staff must verify the patio doors are locked at the beginning and middle of each shift. 6a, 2p, 6p, and 10p. She added staff verify the facility exit doors are locked at the beginning of each shift and signed out on a different sheet.A document titled Education for a questionable resident's wandering dated 8/18/25 educated staff to address the basic needs of an exit-seeking resident and offer diversional activities of the resident's interest. It also educated staff to seek assistance until resident safety is ensured.On 10/16/25 at 1:48 PM, the Director of Nursing (DON) stated the facility door codes were all changed and staff should have met the resident's basic needs at the time he approached her.A policy titled Elopement Risk / Elopement (Missing Resident) Process revised 07/2024 indicated staff would encourage activities which the resident enjoys in order to occupy/distract the resident when the resident is identified at risk for elopement.

Based on clinical record review, family and staff interviews, personnel file review and policy review, the facility failed to provide timely assessment and interventions for 1 of 4 residents who experienced a change in condition (Resident #1). The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 3/26/25 revealed a Brief Interview for Mental Status (BIMS) score had not been completed but indicated his memory was ok. It included diagnoses of anxiety, depression, respiratory failure, secondary malignant neoplasm of unspecified site (cancer that has spread to another location in the body from an unknown origin). It also revealed the resident required supervision with eating, moderate assistance with oral hygiene and upper body dressing, maximum assistance with bathing and lower body dressing, was dependent with toileting hygiene and putting on and removing footwear and required maximum assistance with transfer mobility. It further revealed the resident did not use supplemental oxygen therapy. On 4/10/25 at 12:02 PM, Resident #1's relative stated she arrived on 3/26/25 at 7:00 PM and observed the resident breathing differently and he complained of being cold. She stated she located a Certified Nurse Aide (CNA) and requested the nurse. She asserted Staff A, Licensed Practical Nurse (LPN), verbalized she was passing medications and would respond real soon. The resident's relative indicated she then told Staff B, CNA, that Resident #1 needed help. She stated Staff B and Staff C, CNA, obtained the resident's temperature of 102 degrees Fahrenheit (F) and the oxygen saturation (O2 sat) of 75% on room air. She stated Staff B, CNA, got an oxygen tank and Staff C, CNA placed the resident on oxygen (O2) and notified Staff A, LPN of the resident's temperature (T) and O2 sat. The relative stated Staff A, LPN, arrived to the resident's room approximately 45 minutes after she was initially notified of the relative's concern regarding the resident's condition. On 4/10/25 at 4:07 PM, Staff C, CNA, stated Resident #1 was having trouble breathing on 3/26/25 and she notified the nurse. She said she took the resident's oxygen level (O2 sat) and it was at 75%. She stated she then applied oxygen at two (2) liters per minute (lpm) via nasal cannula (NC) and rechecked the resident's O2 sat which resulted 83%. She stated the Staff A, LPN, arrived 5 - 10 minutes later. She further stated the resident's relative requested the nurse a couple of minutes after she arrived and at least 45 minutes passed before Staff A, LPN, came to see the resident. The Electronic Health Record (EHR) included a physician's order for Albuterol HFA; inhale two (2) puffs into the lungs every 4 hours as needed (PRN) for wheezing/shortness of breath dated 3/24/25 and Oxycodone 5 mg tablet by mouth every 4 hours as needed for pain dated 3/26/25. An EHR progress note dated 3/26/25 at 7:45 PM revealed Staff A, LPN, arrived to the resident's room and checked his vital signs with the following results: blood pressure (BP) 131/93 mmHg, T 98.4 degrees F, respiratory rate (RR) 28, and O2 sat 91%. It also indicated Staff A administered the Albuterol and Oxycodone. It also indicated Staff A asked the resident's relative to give the medication time to work. The EHR O2 Sats Summary indicated Staff A, LPN, documented on 3/26/25 at 8:00 PM the resident's O2 sat was 91% on room air. At 9:00 PM, Staff A, LPN, documented the resident's other relative notified her that an ambulance had been called for Resident #1. Staff A also documented she then contacted the on-call provider to send the resident to the hospital per the family's request. The Emergency Medical Services (EMS) report dated 3/26/25 at 9:20 PM revealed Resident #1 was receiving supplemental O2 at 2 liters per minute (lpm) via nasal cannula. It indicated at 9:26 PM, the resident's O2 sat was 77% and was switched to the EMS O2 tank at 4 lpm via nasal cannula. The Care Plan revised 3/26/25 did not included any respiratory related staff interventions or directives. A Notice of Corrective Action form dated 3/28/25 indicated the facility acknowledged Staff A's failure to provide timely assessment. On 4/16/25 at 1:49 PM, Staff C, CNA, stated she put oxygen on him because he had labored breathing, his O2 sat was 75%, and the family was present asking staff to do something. On 4/16/25 at 2:04 PM, Staff B, CNA stated he heard Staff C call for Staff A to come to the resident's room. He stated he went to the resident's room and the resident reported being short of breath. Staff B stated he got an oxygen tank and notified Staff A that she needed to come to the resident's room. A policy titled Change of condition monitoring process reviewed 2/2025 defined a change of condition as: 1. Accidents where there is direct harm to the resident 2. A noted reaction to a medication 3. Changes in cognitive function 4. A physical decline in resident's condition 5. An emotional change in the resident 6. Any condition change for which the physician directs staff to notify him/her, regarding the resident It also directed the nurse to notify the resident's physician. On 4/16/25 at 3:09 PM, the Director of Nursing (DON) stated the nurse should have addressed the patient and family concerns.

Based on observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 40 residents. Findings included: On 10/16/24 @ 2:38 am, the medication room door was observed propped open with an angled floor stopper. A small basket of over-the-counter medications (OTC) was positioned on top of a small cart. Two (2) medication packets, Prednisone and Furosemide, were lying on the counter. On 10/16/24 at 2:43 am, Staff A, Licensed Practical Nurse (LPN) stated medications were not stored in the medication room. When Staff A was informed there were medications on the medication room counter, he stated the resident didn't want staff in her room before 6:00 am, so he left them there. He also stated the door was closed to prevent residents from accessing them. When he was informed the door was propped open, he stated all of the residents were asleep but confirmed the door should be closed. On 10/17/24 at 4:00 pm, the Director of Nursing (DON) stated the medication room door should be closed if the nurse is not present. A policy titled Medication Administration, Storage, Disposal and Nurse Review revised 9/2020 indicated all prescription medication must be kept in a locked cabinet. All other medications must be stored in a locked area not accessible to person other than employees responsible for administration and storage of medications.

Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access. The facility reported a census of 40 residents. Findings include: On 10/16/24 @ 2:55 am, a document containing resident information was observed on a table in an open area of the unit with no staff present. On 10/16/24 at 2:58 am, Staff A, Licensed Practical Nurse (LPN) stated the form was the 24-hour nurses' report sheet. He also stated he left it out because all of the residents were asleep but it should not be left out when staff are not present. On 10/16/24 at 4:00 PM, the Director of Nursing (DON) stated staff should turn paperwork with resident information over so it's not visible to others. A policy titled Policy Regarding Use and Disclosure of Health Information Pursuant to Resident Authorization revised 1/2015 indicated the facility is committed to protecting the privacy and confidentiality of an individual's Protected Health Information.

Based on observations, clinical record review, staff interview and resident interview, the facility failed to follow physician orders for dressing changes for 1 of 3 resident's (#3) reviewed. The facility reported a census of 40 residents. Findings Include: On 10/16/24 at 9:26 am, a dressing was observed on Resident #3's right shoulder. On 10/17/24 @ 9:45 am, Resident #3 stated her right shoulder dressing was not changed on 10/16/24. The resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated completely intact cognition. It included diagnoses of cancer, depression, right artificial shoulder joint, morbid obesity, and osteoarthritis. It indicated the resident required moderate to maximum assistance with all aspects of Activities of Daily Living (ADLs). It also indicated the resident had no upper extremity limitations. The Electronic Health Record (EHR) included a Physician Order dated 10/12/24 for dressing change to right shoulder as follows: apply ABD pad (thick pad) and change daily one time a day for wound care. The Care Plan did not include any wound care directives for staff. The Progress Notes did not include documentation that indicated the dressing was changed on 10/16/24. The Treatment Administration Record (TAR) for October 2024 included a documented right shoulder dressing change for 10/16/24. On 10/17/24 at 10:10 am, Staff B, Registered Nurse (RN) stated she told Resident #3 to leave the right shoulder wound open to air since it didn't have a dressing on it. She stated she did not put any dressing on it. The TAR had her signature indicating she completed the dressing change. On 10/17/24 at 10:45 am, Staff C, RN stated she changed the resident's right shoulder dressing on 10/15/24. On 10/17/24 at 10:50 am, Staff D, RN stated she did not apply Resident #3's current right shoulder dressing. The facility did not have a policy specific to following physician's orders. On 10/17/24 at 4:00 pm, the Director of Nursing (DON) stated you should not sign off an order until the treatment is completed.

Based on observation, menu review, and staff interview, the facility failed to serve the appropriate portions for 5 residents who received mashed potatoes for lunch. The facility reported a census of 35 residents. Findings include: The facility's menu for lunch for 7/14/24 identified the following items to be served as part of the planned regular textured diet: 3 oz of fried chicken 3 oz of beef tips 1/2 cup of mashed potatoes 1/2 cup of parslied rice 1/2 cup of country vegetable blend 2 oz ladle of country gravy Continuous observation of lunch preparation and service began on 7/14/24 at 11:59 am. Staff G, Homemaker cook, placed the following food serving utensils on a dish and identified each serving size. a) a 4-oz long, green handled spoodle (serving spoon and ladle combination) b) a 4-oz long, green handled ladle c) a 3-oz beige handled ladle d) a short, green handled scoop She was not able to identify the serving size of the short, green handled scoop but stated it was used for the mashed potatoes. At 12:14 PM, Staff G prepared and served the following resident plates. 1st plate - a 3 oz serving of beef tips; a scoop serving of mashed potatoes, a 4-oz serving of gravy. 2nd plate - a scoop serving of mashed potatoes, a 4-oz serving of gravy, and 1 piece of chicken. 3rd plate - a 4-oz serving of country vegetable blend, and 1 piece of chicken. At 12:30 PM, the Dietary Manager (DM) placed a red handled serving ladle on the plate of utensils. Staff G continued to prepare and serve the following resident plates. 4th plate - 1 piece of chicken; a scoop serving of mashed potatoes, a red ladle serving of gravy she identified as a 2-oz serving. 5th plate - a scoop serving of mashed potatoes, a 2-oz serving of gravy, a 4-oz serving of country vegetable blend, and a 3-oz serving of beef tips. 6th plate - a scoop serving of mashed potatoes, a 2-oz serving of gravy, a 4-oz serving of country vegetable blend, and a 3-oz serving of beef tips. 7th plate - a 4-oz serving of country vegetable blend, and 2 pieces of chicken legs. At 12:45 PM, Staff G identified the green handled serving scoop manufacturer which was identified as a 3.3 oz serving size. At 12:57 PM, Staff B, Homemaker cook, stated he used a gray handled serving scoop to plate the residents' mashed potato servings. He identified it as a 4-oz serving size. At 1:40 PM, the DM stated she noticed the incorrect serving scoop had been used for the residents' serving portions. On 7/15/24 at 3:42 PM, the DM stated staff should've followed the therapeutic spreadsheet to ensure the scoops and spoodles match the diet serving size. A document titled Feeding a Resident dated 7/2016 directed staff to check the tray before serving the meal to make sure that everything is on the tray and it is in accordance with the resident's diet.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing and serving food and not wearing beard covering while in the food service area. The facility reported a census of 35 residents. Findings include: 1. On 7/13/24 at 9:45 AM during initial walk through, the following was observed: In the walk in cooler, the following items did not have an open date label: American cheese sandwich cut, butter block, beef base, blue cheese, Milk 2%. In the dry storage room, the following items did not have an open date label: Spaghetti noodles, Elbow noodles, Penne noodles, orange gelatin mix, coconut topping-toasted, pecan nuts topping, graham cracker cookie crumble. The following item was not properly covered and did not have an open label date, spaghetti noodles. In the freezer, the following items were not properly covered and did not have an open date label: ready to bake cookie dough on cookie sheet in freezer and tenderloin patties on cookie sheet in freezer. Chapter 3, Section 202.15, package integrity, of the 2022 FDA Food Code documents: Food packages shall be in good condition and protect the integrity of the contents so that the Food is not exposed to adulteration or potential contaminants. 47079 2. On 7/13/24 at 12:42 PM, Staff A, Homemaker Cook, wiped her ungloved hand on her work jacket then grabbed a small plate from the cabinet. She placed her right thumb on the food surface area of the plate and laid it on the counter. She placed a piece of cake on the spot where her thumb contacted the plate. She repeated the process for a second plate of cake. At 12:47 PM, Staff A removed a resident's plate from his table, opened the trash bin drawer, scrapped the contents into the garbage, and placed the dishes in the sink. She removed more used dishes from the dining tables and emptied the contents into the garbage. She then took a cup from a resident's table, filled it with thickened water, and took it back to the resident. She returned to the kitchenette and placed pieces of cake on more plates. She did not perform hand hygiene throughout the service. On 7/14/24 at 10:20 AM, a follow-up kitchen observation revealed Staff C, a Sous Chef, and Staff D, a Sous Chef, prepared food with uncovered facial hair. On 7/14/24 at 7:24 AM, Staff E, Homemaker Cook, opened a package of cereal, dumped it into a bowl, opened the trash bin drawer, threw away the cereal package, opened the refrigerator door, grabbed the 2% milk from the fridge, poured it into the bowl, and put the milk back in the fridge. No hand hygiene was performed throughout the process. At 7:28 AM, she took the breakfast to the resident's room, uncovered it, and placed the bowl on the resident's table. Her right thumb contacted the inside of the bowl when she placed it on the table. At 7:33 AM, Staff E stated hand hygiene should be performed after touching meats, if hands become soiled, before donning gloves, and after touching the trash bin. On 7/15/24 at 3:42 PM, the Dietary Manager stated staff should wash hands before and after donning and doffing gloves and after touching trash receptacle or garbage. Staff should also wear gloves when touching ready to eat food and should not touch the food surface area of dishes. At 3:58 PM, the Director of Food & Beverage stated everything should be labeled, dated, and covered. A document titled Hand Washing and Hand Hygiene revised 6/20 directed staff to perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not glove are worn; immediately after gloves are removed; and when otherwise indicated to avoid transfer of microorganisms to other residents, personnel, equipment, and/or the environment. A document titled Infection Control Manual Dietary Department dated 8/1/19 indicated the dietary department will work to comply with all state, federal and local infection control standards and regulations concerning personnel requirements, food storage, preparation handling and serving, sanitizing equipment and utensils, and isolation procedures.

Based on review of documents, observations, resident, and staff interviews, the facility did not ensure: 1. Assistance for safe ambulation 2. Implementation of safe transfer techniques after a fall 3. Supervision during the use of restorative equipment, for 1 of 4 residents (Resident #11) in the sample reviewed for accidents. 4. In addition, the facility did not consistently investigate fall incidents to determine root causes, in order to develop appropriate interventions to prevent or minimize potential occurrences, the facility did not consistently reflect assessments data, and interventions implemented related to falls in the clinical records for 1 of 4 residents (Resident #11) in the sample reviewed for accidents. The facility reported a census of 38 residents at the time of the survey. Findings include: Resident #11's electronic medical records identified an admitted [DATE]. Resident #11's medical diagnoses included [CONDITION(S)] and [CONDITION(S)] (weakness, stiffness, and lack of control on one side of the body) following a cerebral infarction affecting her right dominant side, and low back pain. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] indicated his active diagnoses included [CONDITION(S)], acute [CONDITION(S)], and depression. The MDS documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impaired cognition. The MDS identified Resident #11 needed extensive assistance of one person for bed mobility, transfers, ambulation, personal hygiene, dressing, and toilet use. Resident #11 needed supervision with set up help to eat. The MDS also indicated Resident #11 as being unsteady and could only stabilize with staff assistance for balance during transitions, transfers, and walking. The MDS further indicated that Resident #11's used a 4 ww (wheeled-walker) and wheelchair as mobility devices. The section related to restorative nursing programs indicated Resident #11 had 0 to less than 15 minutes of restorative programs in the previous seven calendar days. Resident #11's MDS assessment dated [DATE] identified a BIMS score of 11, indicating moderate cognitive impairment. The MDS indicated that Resident #11 required extensive assistance of two persons for bed mobility, transfers, dressing, and toilet use. Resident #11 used extensive assistance of one person for locomotion on the unit and personal hygiene. verified facility report about having 3 falls since admission On 7/18/22 at 10:16 AM, observed Resident #11 sitting in his wheelchair in his room, alert, and signifying permission for the surveyor to enter for a routine survey interview. Resident #11 affirmatively replied to the inquiry regarding falls, and reported he sustained injury as a result of a fall. When asked of any changes in his cares related to the falls, Resident #11 said that the staff members now used a device to help him stand and transfer. On 7/20/22 at 10:05 AM, watched Staff C, CNA (Certified Nurse Aide), push an EZ stand (Standing mechanical lift) in the hallway towards Resident #11's room. Staff C explained that she was waiting for a Hospice staff member to assist with Resident #11. Staff C corroborated Resident #11's statement about needing to use an EZ stand and always with assistance of two people for all transfers. On 7/20/22 at 10:16 AM, Resident #11 verified that he fell three times since admitting to the facility. Resident #11 reported that he fell while using an exercise machine. Resident #11 said that he wanted to get off but no staff were there to help. Resident #11 also said during another one of his falls, he went walking with a staff member but could not remember if they used a gait belt. Resident #11 explained another fall when he slid down (pointing at the brown chair), saying he had to go to the bathroom. When asked if he used his call light when he needed to go to the bathroom, Resident #11 replied, Got to have called and nobody was coming. Care Plan review The resolved Care Plan Focus area initiated on 1/12/22 and resolved on 3/23/22 directed that Resident #11 had limited physical mobility. The connected goal indicated that Resident #11 would maintain his current level of mobility of one assist with activities of daily living (ADLs) and be able to walk with 4 ww short distances through review date. The Care Plan included the following interventions initiated on 1/12/22 and got resolved on 3/23/22 a. Nursing rehab/restorative: active range of motion (ROM) Program bilateral upper extremities (BUE) strengthening exercises weight as Resident #51 could tolerate up to two pounds, three times a week. b. Nursing rehab/restorative: active rom Program NuStep (exercise bike that works upper and lower body) exercise for all extremities, time, and resistance to Resident #11's tolerance of three times per week. The Care Plan Focus area revised 12/16/21 identified Resident #11 as a high risk for falls related to deconditioning, unaware of his safety needs, [CONDITION(S)] from a previous cardiovascular accident ([CONDITION(S)]). The attached goal initiated 12/16/21 documented that Resident #11 would have no serious injuries due to falls through the next review date. The Care Plan Focus included the following interventions a. Revised 2/24/22: Fall intervention: x-rays, emergency room (ER) evaluation, gait belt education for Certified Nurse Aides (CNA's). b. Initiated: 2/24/22: Anticipate and meet the resident's needs. c. Revised 12/16/21: Assist with toileting needs d. Initiated 12/16/21: Assist with toileting needs as needed (PRN). e. Initiated 1/20/22: Resident #11 is not to be left unattended on the NuStep. f. Revised 1/22/22 Intervention - urinalysis (UA) with culture and sensitivity (C&S). g. Initiated 1/25/22, Resolved 2/26/22: Keep Resident #11's walker close to him regardless of his location in his room. Initiated 12/16/21: Resident #11 would like to be encouraged and assisted with wearing non-skid footwear for all mobility attempts Initiated 12/16/21: Resident #11 would like to keep his room clutter-free. Resident #11's Restorative Nursing document dated 1/7/22, identified therapy recommendations from Physical Therapy (PT). The Restorative Identified Needs indicated the following programs a. NuStep exercise for BUE and lower extremities (LE) at time and resistance to the patient's tolerance. b. Ambulate patient with contact guard assist (CGA) with 4 ww distance to patient's tolerance. c. Upper extremity (UE) strengthening up to two pounds gross motor coordination (GMC) activities three times per week. Despite the care plan above, Resident #11 incurred fall incidents, as follows: The facility's records of incidents showed that Resident #11 had fall incidents related to failure to follow care plan, as follows: a. 1/20/22 at 1:30 PM: Unwitnessed fall from the NuStep in the [NAME] Living Room. i. The January 2022 Documentation Survey Report lacked documentation of Resident #11's ADLs indicating completion for the 6 AM to 2 PM shift on 1/20/22 or during the time of his fall. ii. In addition, despite Resident #11 having used the NuStep and falling from it, Resident #11's record lacked documentation of his performance of the NuStep activity on the same date. 1. FALL 1/20/22 (Unwitnessed). The Incident Report dated 1/20/22 at 1:30 PM labeled unwitnessed documented that the nurse got a call to the [NAME] living room area of the facility. The CNA reported that Resident #11 on the floor near the NuStep. When the nurse entered the living room, she observed the resident sitting parallel to the NuStep. Resident #11 sat upright with his feet outstretched in front of him with his hands on either side of his body holding him upright. The nurse assessed no injuries and his vitals were within stable. Two staff assisted Resident #11 up with a Hoyer Lift. Resident #11 denied pain, discomfort, or that he hit his head. When the nurse asked Resident #11 what happened, he responded that he decided to get off the machine and he slid off the edge of the seat. The Immediate Action Taken included an intervention for Resident #11 to not be left unattended while using the NuStep. The January 2022 Documentation Survey Report recorded that on 1/20/22, Resident #11's ADLs were not signed from 6 AM to 2 PM, which covered the time of the incident. The report lacked documentation regarding Resident #11's performance on the NuStep for his restorative plan and who assisted Resident #11 during the activity. Additionally the progress notes lacked entries to show Resident #11's incident on 1/20/22, including pertinent assessments and interventions. Resident #11's clinical records lacked evidence regarding a follow-up investigation after his fall regarding a root cause analysis, the staff involved, and the appropriateness of the intervention. On 7/25/22 at 11:39 AM, Staff C showed the NuStep equipment used by residents on a restorative at [NAME] Unit. Staff C said she got trained to not leave residents while in there (pointing at the NuStep). When asked if residents using the NuStep could call for help if they needed to get off, Staff C replied, No call button on the NuStep because staff should be present all the time. Staff C showed a portable call system, but said that residents who sat in the living room and watched television used it. Staff C added that they should assist residents that fell with the Hoyer lift, and not stand them up. On 7/25/22 at 11:44 AM, Staff D, CNA, verified that she worked on the [NAME] Unit when Resident #11 fell from the NuStep machine. Staff D denied knowing who put him there and left him unattended. Staff D said that no one is supposed to be left alone on the NuStep machine. On 7/26/22 at 11:14 AM, when asked about supervision for residents who used the NuStep machine, the Director of Nursing (DON) reported that residents could be left unattended if they ask to use the NuStep machines because they have that right. The DON stated that they have a restorative aide but if she's not here, and a resident asks to be put on the machine, that request could be honored. The DON said, it maybe what happened with Resident #11 because prior to the fall on 1/20/22, Resident #11 had intact cognition. The DON said that Resident #11 could be left unattended using the NuStep machine. The DON added that she completed the investigation from Resident #11's fall, and discovered that an agency staff member signed the restorative nursing documentation. The DON explained with that documentation she determined who put Resident #11 on the NuStep machine, and that she (the Agency staff) could do that if Resident #11 requested. The DON said she completed the investigation regarding the fall but she didn't know if at that time, Resident #11 requested to use the NuStep by himself. The DON further said that the ADON (Assistant Director of Nursing) was still digging to look for investigation notes about the incident because those were filed separately. The DON stated she would not expect witnesses for fall incidents with use of restorative equipment for residents who use or request these equipment on their own because nobody is there. The DON also stated that the facility properly implemented interventions in handling/addressing fall incidents such as Resident #11's fall on 2/22/22 because the CNA who was with Resident #11 at the time had been coached and educated. On 7/27/22 at 12:30 PM, the DON provided the January 2022 Restorative Nursing Documentation, which lacked documentation for Resident #11's Restorative Nursing activities on the date of his fall (1/20/22). 2. FALL 1/22/22 (Unwitnessed). The Incident Report dated 1/22/22 at 10:45 AM labeled unwitnessed indicated a CNA notified the nurse of Resident #11 on the floor in his room in front of his closet with his head close to the closet and his body parallel with the dresser with his feet outstretched. Resident #11 explained that he woke up from a nap in his recliner. He thought that he could get up and go to the bathroom, so he attempted to get out of the recliner to get his walker. The nurse noted Resident #11's walker across from him as he didn't previously use it on a consistent basis. Resident #11 reported that he lost his balance and fell to the floor. He denied hitting his head. The staff placed Resident #11 into his bed with the use of a hoyer and two staff members. Two Registered Nurses (RN) assessed him with no injuries noted. The nurse got an order for a urinalysis (UA) with culture and sensitivity (C&S). On 7/25/22 at 11:59 AM, Staff E, RN (Registered Nurse), reported that she was on orientation when the incident happened, however, she verified that she documented about Resident #11's incident. Staff E verified that Resident #11's clinical progress notes lacked documentation about the fall but said there is another place where they document about it, and showed her own documentation in the computer. Staff E verified that the contents of her documentation in the computer are the same as the ones provided to the surveyor in hard copy (incident record), that contained the label Privileged and Confidential - Not part of the Medical Record - Do not copy. During an inquiry about the process for handling resident falls, Staff E replied that it would be to assess the resident before moving them and then assist the resident up from the floor with a Hoyer lift. If the resident complained of pain, or had any signs of injury, they should send the resident to hospital immediately for evaluation. Staff E said that she would not wait for a Portable X-ray. Staff E added that in regards to notifying a physician about an acute or emergency event, she said that she would call the physician's office and she wouldn't stop until she got an answer. Resident #11's clinical records lack entries pertinent to the fall, including assessments and interventions with regard to the fall when it happened on 1/22/22. The records also lack evidence of follow-up investigation regarding the surrounding circumstances of the incident. 3. FALL 2/22/22 (Witnessed). The Incident Report dated 2/22/22 at 7:30 AM labeled Unwitnessed Fall documented that while ambulating (walking) to the bathroom with his 4 ww, staff observed Resident #11 falling to the floor on his left side. Resident #11 didn't hit his head but did get a skin tear to his right hand. Resident #11 described that he complained of weakness and lost his balance. The nurse got an order to do an x-ray to his lower back and left hip. The report indicated that Resident #11 didn't go to the hospital. Resident #11 complained of pain at a 5 out of 10, indicating moderate pain. The Incident Report listed Resident #11's mobility as ambulatory with assistance. The Predisposing Physiological Factors listed weakness/fainted and gait imbalance. The Predisposing Situation Factors listed ambulating with assistance and using a wheeled walker. The form documented no witnesses found. On 7/18/22 at 10:16 AM, Resident #11's interview indicated he had a fall with injury. On 7/20/22 at 10:16 AM, Resident #11 verified that he had three falls since his admission to the facility, including an incident where he was walking with a staff member. Resident #11 could not remember if the staff member used a gait belt or held on to it during his fall. On 7/20/22 at 10:41 AM, Staff G, Registered Nurse (RN), confirmed that she worked as the nurse for Resident #11 during the fall on 2/22/22. Staff G identified Staff H, CNA, as the CNA who let go of the gait belt while ambulating Resident #11 to the bathroom. Staff G reported that after her assessment, the three of them, herself with Staff H and Staff F, CNA, lifted Resident #11 from the floor without using the Hoyer lift. Staff G said they should have followed protocol and used a Hoyer lift to transfer Resident #11 from the floor. Staff G said Resident #11 ate breakfast but complained of pain, and asked for pain medication (Tylenol). Staff G said she then obtained an order for X-ray. Staff G reported Resident #11 also vomited after lunch. Staff G further explained that when she notified the physician's office about the X-ray result, they ordered her to send Resident #11 to the hospital. When asked if they followed the facility's fall protocol in handling Resident #11's fall, Staff G answered that they didn't follow the protocol to use a Hoyer lift. On 7/20/22 at 2:39 PM, Staff F, CNA, said she worked the day when Resident #11 fell . Staff F said it was Staff H who helped Resident #11 at the time of the fall. Staff F said, she did not know how the fall happened but [Staff H] came and got her. Staff F explained that she told Staff H that she was going to get the nurse. Staff F reported that Staff H left Resident #11 on the floor and went out to get her (Staff F). Staff F added that when she entered the room, Resident #11 laid on the floor halfway to the bathroom, in front of his recliner. Staff F identified Staff G as the nurse who worked that day. Staff F said Staff G assessed Resident #11 and decided that the three of them could pick Resident #11 up from the floor. Staff F reported that they helped Resident #11 from the floor to his wheelchair, then to the bathroom, where they transferred him to use the toilet. While there, they got him dressed and then they took him to his usual dining room for breakfast. When asked if Resident #11 complained of pain during the transfer, Staff F replied Resident #11 was complaining of a little discomfort but then more after breakfast, and then they got an order for an X-ray. When asked if they did the proper interventions in handling Resident #11's fall, Staff F replied, No, we should not have picked him up. The excerpt of the Progress Notes dated 2/22/22 below document the timeline of more than 6.5 hours following Resident #11's that he complained of discomfort and increasing weakness until his hospital transfer: a. At 7:30 AM, staff observed Resident #11 losing balance and falling while walking to the bathroom with a 4 ww. The note indicated that Resident #11 complained of lower back pain. The note continued to record that staff assisted Resident #11 up, as he could bear weight without difficulty. b. At 9:08 AM, the nurse administered a pain reliever (2 tablets of Tylenol 325 milligrams, (MG)). c. At 12:03 PM, the nurse gave another dose of pain reliever (2 tablets of Tylenol 325 MG). d. At 1:00 PM, the facility received the results of the X-ray and notified the physician's office of the results. e. At 1:20 PM, staff noted Resident #11 to have increased weakness, and had a large emesis (vomit) of undigested food after lunch. f. At 2:00 PM, the facility received an order from physician's office to send Resident #11 to the hospital for evaluation. g. At 2:15 PM, the facility transferred Resident #11 to the hospital. The document titled, Patient Report dated 2/22/22 contained Resident #11's X-ray results due to pain following a fall. The impression indicated Resident #11 had a probable comminuted fracture deformity noted along the left acetabular roof (the main weight-bearing area of the hip joint). The Nurses Note dated 2/23/2022 at 6:26 AM, also showed a nurse's follow-up call to the hospital, which confirmed Resident #11 got admitted to the hospital with a diagnosis of a pelvic fracture. Resident #11's decline following his fall a. The Hospital Discharge orders dated 2/25/22, showed Resident #11 discharged to the nursing facility with hospice services. b. The Significant Change MDS dated [DATE], identified Resident #11 required extensive assistance of two persons for bed mobility, transfers, personal hygiene, and toilet use; and total dependence for locomotion off the unit of one person. The MDS coded that Resident #11 received hospice services during the lookback period c. The updated Care Plan reflected Resident #11 received hospice services, and increased assistance requirements with his ADLs. d. The follow-up X-ray results dated 5/2/22, indicated that Resident #11's pelvic fractures remain with no convincing evidence of interval healing. e. The Physical Therapy Evaluation documentation dated 5/6/22, showed use of an EZ stand to transfer Resident #11. On 7/25/22 at 12:49 PM, when asked about notifications of change or occurrences, Resident #11's Family Member replied that facility called her about those, including all of Resident #11's falls. When asked about the fall with injury that happened on 2/22/22, Resident #11's Family Member replied that she received a call at 7:30 AM that day. Resident #11's Family Member said that the first thing she asked during the call was was he hurt?. Resident #11's Family Member explained that she got told that Resident #11 already went to breakfast. Resident #11's Family Member said the caller didn't know if Resident #11 got injured but the caller assured Resident #11's Family Member that they would get an order for an X-ray. Resident #11's Family Member said the fall might have happened at around 7:20 AM, because she got notified at 7:30 AM. Resident #11's Family Member explained that by the time she arrived to the facility at 9:00 AM, she noted the X-ray person still in the hallway saying that he just finished working with Resident #11. Resident #11's Family Member said there had been a lot of movement after the fall and before his hospital admission at 2:30 PM. Resident #11's Family Member reported that they did another X-ray that pointed out the fracture all the way across. On 7/25/22 at approximately 11:14 AM, the DOT (Director of Therapy) said residents under therapy services could not be left by themselves while using therapy equipment. The DOT stated expectations that the staff must attend to residents throughout the entire therapy session. On 7/27/22 at 3:20 PM, at the exit conference, the facility continued to not provide any documentation regarding the investigation of Resident #11's fall from the NuStep. The DON again said that Resident #11 requested to use the NuStep that day by an Agency staff who honored his request. The DON added on the recording that the Restorative Aide helped the resident use the NuStep, and the other staff who got interviewed didn't know the process. The DON further explained that Resident #11 asked an Agency CNA to use the NuStep, so the Agency CNA assisted him onto the NuStep. While on the NuStep, he pedaled independently and prior to the Agency CNA's return he decided to get off the machine on his own. The DON said the residents have the right to use the NuStep if they wish, and she was not going to stop them from doing that as it was their right. The DON further said they will have more investigation information regarding the fall to be submitted to the office in two business days from the exit date. Facility Policy Review The Gait Belt Use, revised 7/16, directed the staff person to utilize safe transfer techniques, by moving with the resident, with their knees bent, and a strong grasp on the transfer belt. The form included that if using a wheelchair, place it on the resident's strongest side. The Accident/incident Prevention Process, revised 6/20, instructed that all nursing staff were required to complete training specific for safe patient handling policy and proper equipment utilization. The form indicated that the Competencies would be completed as follows: a. Upon hire b. After completion of mentor program c. Annually d. After an injury related to transferring, repositioning, or lateral transfers if the investigation determines if improper technique and/or process related to the cause of the incident. e. Competencies must be done with visual return demonstration and be documented in the team members personnel file. f. Any team member off work for 90 or more consecutive days would be required to complete a competency skill check prior to the team member returning to his/her regular duties in the health center. The Restorative Program Procedure, revised 11/20, provides that it refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. The procedure provided that measurable goals and interventions must be documented in the care plan and in the medical record. The procedure also directs staff to write progress notes written by the restorative aid and countersigned by a licensed nurse is sufficient to document the restorative nursing program once the purpose and objectives of treatment have been established. Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity, and a nurse must supervise the activities in the restorative nursing program. The Safe Resident/Client Transfer Procedure, revised 4/14, indicated that it is the facility's policy that manual lifting of residents will be minimized or eliminated whenever possible. The policy also provides that it is done for the safety of the residents, clients, participants, and team members during transfer and repositioning tasks. The Procedure directs the following. a. Gait-belt assistance-one person i. The resident can stand for at least 5 seconds, using mobility equipment such as walker ii. The resident requires supervision or contact assistance when ambulating iii. Assistance with sitting to standing may be required by assisting the resident to a standing position. The transfer status will be noted on the care plan, and the change in transfer status will be communicated to other team members at the change of each shift. b. If a resident falls, a medical assessment will be completed by a nurse, and if there is a medical concern, appropriate measures will be taken to notify emergency personnel, the resident should remain on the floor, made comfortable, and medically monitored until emergency responders arrive. i. If the resident is medically stable, was previously independent, and can get up on his/her own, a gait belt can be placed on the resident to assist with steadying. The staff member should not be using the gait belt to lift the resident from the floor. ii. If the resident is medically stable yet is unable to get off the floor on his/her own, a total body lift will be used regardless of transfer status. c. Training i. All team members will be required to demonstrate competency with transfer, repositioning, and lateral transfers in a controlled environment prior to being permitted to complete these tasks with residents. ii. It is expected that the policy will be followed at all times. d. Additional information i. Any injury resulting from transferring, repositioning, or laterally transferring a resident will go through an injury review process to determine root cause and to define corrective actions which can minimize the risk of another injury of this type from occurring again.

Based on clinical record reviews, review of the Notice of Transfer to the Long Term Care Ombudsman form, and staff interviews, the facility failed to notify the Long Term Care (LTC) Ombudsman of resident transfers for two of three residents reviewed for hospitalization (Residents #37 and #11). The facility reported a census of 38 residents. Findings include: 1. Resident #37's Minimum Data Set (MDS) assessment dated [DATE] documented a reentry date of 7/14/21 after an acute hospital stay. The MDS indicated that Resident #37's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Electronic Health Record (EHR) Census list recorded Resident #37 transferred to the hospital on 7/13/21, and returned to the facility 7/14/21. The Nurses Note dated 7/13/21 at 6:30 PM indicated that Resident #37 got admitted to the hospital for a fractured pelvis. The Admission Summary Note dated 7/14/21 at 5:15 PM documented that Resident #37 returned from the hospital. The July 2021 Notice of Transfer Form to the LTC Ombudsman lacked Resident #37's name on the form when she transferred to the hospital on 7/13/21. In an email received on 7/20/22 at 3:43 PM, Staff A, Social Worker, wrote that Resident #37 went to the hospital on 7/13/21 and came back on 7/14/21. Due to the short-time gone, she did not trigger as a discharge to go on the (Ombudsman) form. On 7/26/22 at 10:20 AM, Staff A reported that she ran a report from the EHR for residents that discharged from the facility. Staff A explained that she then submitted a list of residents who had transferred or discharged from the facility each month to the LTC Ombudsman. Staff A stated she believed Resident #37 returned to facility after she got hospitalized , therefore she did not show up on the report. On 7/27/22 at 1:00 PM, the Assistant Director of Nursing reported a bedhold didn't trigger resident discharges for Resident #37 or Resident #11, and she believed they had a glitch in their EHR. The ADON reported that they had their nurse consultant working on the issue. 2. Resident #11's electronic medical records (EMR) showed an admitted [DATE]. Resident #11's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11's latest quarterly MDS (Minimum Data Set) dated 5/31/22, showed a BIMS (Brief Interview for Mental Status) score of 11, indicating moderately impaired cognition. The MDS included an entry date of 2/25/22 as a reentry from an acute hospital. On 7/18/22 at 10:16 AM, observed Resident #11 sitting in his wheelchair in his room, alert, and signified permission for the surveyor to enter for a routine survey interview. Resident #11 affirmatively replied to the inquiry regarding falls, and reported he sustained injury as a result of a fall. The Nurses Note dated 2/22/22 at 2:05 PM, documented that the facility received an order from physician's office to send Resident #11 to the hospital for evaluation. The Nurses Note dated 2/22/22 at 2:15 PM, recorded that the facility transferred Resident #11 to the hospital. The document titled, Patient Report dated 2/22/22 contained Resident #11's X-ray results due to pain following a fall. The impression indicated Resident #11 had a probable comminuted fracture deformity noted along the left acetabular roof (the main weight-bearing area of the hip joint). The Nurses Note dated 2/23/2022 at 6:26 AM, also showed a nurse's follow-up call to the hospital, which confirmed Resident #11 got admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Hospital Discharge orders dated 2/25/22, documented that Resident #11 discharged back to nursing facility with hospice services. The February 2022 Notice of Transfer Form to Long Term Care Ombudsman lacked Resident #11's transfer to the hospital on 2/22/22.

Based on clinical record reviews, observations, facility policy review, resident, and staff interviews, the facility failed to develop comprehensive Care Plans for two of fifteen residents reviewed (Residents #11 and #51). Resident #11 fell twice due to staff not following the Care Plan. Resident #51 received [CONDITION(S)] care and his Care Plan lacked the required documentation for residents who receive [CONDITION(S)]. Resident #51's Care Plan lacked the staff directives for monitoring his [CONDITION(S)] access site for a bruit, a thrill, bleeding, or other potential adverse problems related to [CONDITION(S)] treatments. The Care Plan lacked instructions regarding performing pre and post [CONDITION(S)] assessments, [CONDITION(S)] center information, emergency contact information, transportation arrangements to and from [CONDITION(S)]. The facility reported a census of 38 residents at the time of the survey. Findings include: Resident #11's electronic medical records identified an admitted [DATE]. Resident #11's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11's Minimum Data Set (MDS) assessment dated [DATE] indicated his active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impaired cognition. The MDS identified Resident #11 needed extensive assistance of one person for bed mobility, transfers, ambulation, personal hygiene, dressing, and toilet use. Resident #11 needed supervision with set up help to eat. The MDS also indicated Resident #11 as being unsteady and could only stabilize with staff assistance for balance during transitions, transfers, and walking. The MDS further indicated that Resident #11's used a 4 ww (wheeled-walker) and wheelchair as mobility devices. The section related to restorative nursing programs indicated Resident #11 had 0 to less than 15 minutes of restorative programs in the previous seven calendar days. Resident #11's MDS assessment dated [DATE] identified a BIMS score of 11, indicating moderate cognitive impairment. The MDS indicated that Resident #11 required extensive assistance of two persons for bed mobility, transfers, dressing, and toilet use. Resident #11 used extensive assistance of one person for locomotion on the unit and personal hygiene. verified facility report about having 3 falls since admission The resolved Care Plan Focus area initiated on 1/12/22 and resolved on 3/23/22 directed that Resident #11 had limited physical mobility. The connected goal indicated that Resident #11 would maintain his current level of mobility of one assist with activities of daily living (ADLs) and be able to walk with 4 ww short distances through review date. The Care Plan included the following interventions initiated on 1/12/22 and got resolved on 3/23/22 NURSING REHAB/RESTORATIVE: ACTIVE range of motion (ROM) Program bilateral upper extremities (BUE) strengthening exercises weight as Resident #51 could tolerate up to two pounds, three times a week. NURSING REHAB/RESTORATIVE: ACTIVE ROM Program NuStep (exercise bike that works upper and lower body) exercise for all extremities, time, and resistance to Resident #11's tolerance of three times per week. The Care Plan Focus area revised 12/16/21 identified Resident #11 as a high risk for falls related to deconditioning, unaware of his safety needs, [CONDITION(S)] from a previous cardiovascular accident ([CONDITION(S)]). The attached goal initiated 12/16/21 documented that Resident #11 would have no serious injuries due to falls through the next review date. The Care Plan Focus included the following interventions a. Revised 2/24/22: Fall intervention: x-rays, emergency room (ER) evaluation, gait belt education for Certified Nurse Aides (CNA's). b. Initiated: 2/24/22: Anticipate and meet the resident's needs. c. Revised 12/16/21: Assist with toileting needs d. Initiated 12/16/21: Assist with toileting needs as needed (PRN). e. Initiated 1/20/22: Resident #11 is not to be left unattended on the NuStep. f. Revised 1/22/22 Intervention - urinalysis (UA) with culture and sensitivity (C&S). g. Initiated 1/25/22, Resolved 2/26/22: Keep Resident #11's walker close to him regardless of his location in his room. Initiated 12/16/21: Resident #11 would like to be encouraged and assisted with wearing non-skid footwear for all mobility attempts Initiated 12/16/21: Resident #11 would like to keep his room clutter-free. Resident #11's Restorative Nursing document dated 1/7/22, identified therapy recommendations from Physical Therapy (PT). The Restorative Identified Needs indicated the following programs a. NuStep exercise for BUE and lower extremities (LE) at time and resistance to the patient's tolerance. b. Ambulate patient with contact guard assist (CGA) with 4 ww distance to patient's tolerance. c. Upper extremity (UE) strengthening up to two pounds gross motor coordination (GMC) activities three times per week. On 7/20/22 at 10:16 AM, Resident #11 reported that he fell while using an exercise machine. Resident #11 said that he wanted to get off but no staff were there to help. Resident #11 also said during one of his falls, he went walking with a staff member but could not remember if they used a gait belt. The facility's records of incidents showed that Resident #11 had fall incidents related to failure to follow care plan, as follows: a. 1/20/22 at 1:30 PM: Unwitnessed fall from the NuStep in the [NAME] Living Room. i. The January 2022 Documentation Survey Report lacked documentation of Resident #11's ADLs indicating completion for the 6 AM to 2 PM shift on 1/20/22 or during the time of his fall. ii. In addition, despite Resident #11 having used the NuStep and falling from it, Resident #11's record lacked documentation of his performance of the NuStep activity on the same date. Staff interviews On 7/25/22 at 11:39 AM, Staff C, CNA, showed the NuStep equipment used by residents on a restorative at [NAME] Unit. Staff C said she got trained to not leave residents while in there (pointing at the NuStep). On 7/25/22 at 11:44 AM, Staff D, CNA, verified that she worked on the [NAME] Unit when Resident #11 fell from the NuStep machine. Staff D denied knowing who put him there and left him unattended. Staff D said that no one is supposed to be left alone on the NuStep machine. On 7/26/22 at 11:14 AM, when asked about supervision for residents who used the NuStep machine, the Director of Nursing (DON) reported that residents could be left unattended if they ask to use the NuStep machines because they have that right. The DON stated that they have a restorative aide but if she's not here, and a resident asks to be put on the machine, that request could be honored. The DON said, it maybe what happened with Resident #11 because prior to the fall on 1/20/22, Resident #11 had intact cognition. The DON said that Resident #11 could be left unattended using the NuStep machine. The DON added that she completed the investigation from Resident #11's fall, and discovered that an agency staff member signed the restorative nursing documentation. The DON explained with that documentation she determined who put Resident #11 on the NuStep machine, and that she (the Agency staff) could do that if Resident #11 requested. On 7/27/22 at 12:30 PM, the DON provided the January 2022 Restorative Nursing Documentation, which lacked documentation for Resident #11's Restorative Nursing activities on the date of his fall, 1/20/22. b. On 2/22/22, Resident #11 had a witnessed fall while ambulating to the bathroom with a 4 ww. On 7/20/22 at 10:41 AM, Staff G, Registered Nurse (RN), confirmed that she worked as the nurse for Resident #11 during the fall on 2/22/22. Staff G identified Staff H, CNA, as the CNA who let go of the gait belt while ambulating Resident #11 to the bathroom. Staff G reported that after her assessment, the three of them, herself with Staff H and Staff F, CNA, lifted Resident #11 from the floor without using the Hoyer lift. Staff G said they should have followed protocol and used a Hoyer lift to transfer Resident #11 from the floor. The Nurses Note dated 2/22/22 at 2:05 PM, documented that the facility received an order from physician's office to send Resident #11 to the hospital for evaluation. The Nurses Note dated 2/22/22 at 2:15 PM, recorded that the facility transferred Resident #11 to the hospital. The document titled, Patient Report dated 2/22/22 contained Resident #11's X-ray results due to pain following a fall. The impression indicated Resident #11 had a probable comminuted fracture deformity noted along the left acetabular roof (the main weight-bearing area of the hip joint). The Nurses Note dated 2/23/2022 at 6:26 AM, also showed a nurse's follow-up call to the hospital, which confirmed Resident #11 got admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's policy titled, Comprehensive Care Plan Process, revised on 12/21, directed that the facility must develop and implement a comprehensive person-centered Care Plan for each resident to meet the resident's medical, nursing, mental, and psychosocial needs as identified from the comprehensive assessment. The policy indicated that the services were to be furnished to attain or maintain the residents' highest physical, mental, and psychosocial well-being. 2. Resident #51's MDS assessment dated [DATE] included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified that Resident #51 received [CONDITION(S)] during the lookback period. The Care Plan Focus area revised 7/12/22 indicated that Resident #51 needed hemodialysis related to renal failure. The included interventions dated 7/12/22 directed the following a. Do not draw blood or take blood pressure in the arm with the graft. b. Monitor for dry skin and apply lotion as needed. c. Monitor labs and report to the doctor as needed. d. Monitor, document, and report as needed (PRN) any signs or symptoms of infection at the access site such as redness, swelling, warmth or drainage. e. Monitor, document, and report PRN for signs or symptoms of renal insufficiency such as changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. f. Monitor, document, and report PRN new or worsening peripheral [CONDITION(S)]. The Care Plan Focus area revised 7/12/22 identified that Resident #51 had an activities of daily living (ADL) self-care performance deficit related to Rhabdomyolysis (A breakdown of muscle tissue that releases a damaging protein into the blood.). The included interventions revised 7/18/22 instructed that Resident #51 needed a hoyer sheet under him on Tuesdays, Thursdays, and Saturday mornings for [CONDITION(S)]. The Care Plan lacked staff directives for monitoring Resident #51's [CONDITION(S)] access site for a bruit, a thrill, bleeding, or other potential adverse problems related to [CONDITION(S)] treatments. The Care Plan lacked instructions regarding performing pre and post [CONDITION(S)] assessments, [CONDITION(S)] center information, emergency contact information, transportation arrangements to and from [CONDITION(S)]. The Nurses Note dated 7/14/22 at 1:14 AM recorded that Resident #51 had [CONDITION(S)] on Tuesday, Thursdays, and Saturdays, with a pick-up time at 9:40 AM. The Progress Notes lacked documentation of assessments of Resident #51's access site or pre and post [CONDITION(S)] assessments. The July 2022 Medication Administration Records (MAR) lacked documentation for an assessment of bruit or thrill to assess patency of the fistula site, monitoring bleeding, increased pain, drainage, or other signs or symptoms of adverse problems related to [CONDITION(S)] treatments or his access site. On 7/17/22 at 3:10 PM, Resident #51 reported he went to [CONDITION(S)] on Tuesdays, Thursdays, and Saturdays. On 7/26/22 at 10:10 AM, Staff B, Registered Nurse, reported that whenever a resident got admitted to the facility and had [CONDITION(S)], the admission nurse entered the orders in the computer for pre/post [CONDITION(S)] assessments. Staff B stated the pre/post [CONDITION(S)] assessments got documented in the EHR under the assessment tab, with the resident's vital signs, and weights. On 7/27/22 at 1:35 PM, the MDS Coordinator reported she developed and updated each of the residents ' Care Plans. The MDS Coordinator explained that she obtained information for the Care Plans from a number of sources, including therapy notes, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If a resident received [CONDITION(S)], it depended on the individual about what went on the Care Plan. The [CONDITION(S)] Process policy revised 7/18 listed that the nurse documented the assessment of the venous access site, vital signs,labs, and weights, if ordered, to assure each resident received care and services for the provision of hemodialysis consistent with professional standards of practice, while ensuring medical information coordinated between the community and [CONDITION(S)] center pre and post [CONDITION(S)]. Venous access identification of the arm for blood pressure documented on the MAR, Care Plan, and the Care Guide in the resident's room. A Comprehensive Care Plan Process policy revised 12/21 revealed a comprehensive person-centered care plan developed for each resident that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychological needs. Care Plans must describe the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive Care Plan outlined any specialized services or services provided or arranged by the community.

Based on clinical record reviews, staff interviews, and facility policy review, the facility failed to complete nursing assessments and monitoring of one of two residents before and after outpatient [CONDITION(S)] treatments (Resident #51). The facility reported a census of 38 residents. Findings include: Resident #51's MDS assessment dated [DATE] included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified that Resident #51 received [CONDITION(S)] during the lookback period. The MDS indicated that Resident #51 admitted to the facility on [DATE]. The Care Plan Focus area revised 7/12/22 indicated that Resident #51 needed hemodialysis related to renal failure. The included interventions dated 7/12/22 directed the following a. Do not draw blood or take blood pressure in the arm with the graft. b. Monitor for dry skin and apply lotion as needed. c. Monitor labs and report to the doctor as needed. d. Monitor, document, and report as needed (PRN) any signs or symptoms of infection at the access site such as redness, swelling, warmth or drainage. e. Monitor, document, and report PRN for signs or symptoms of renal insufficiency such as changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. f. Monitor, document, and report PRN new or worsening peripheral [CONDITION(S)]. The Care Plan Focus area revised 7/12/22 identified that Resident #51 had an activities of daily living (ADL) self-care performance deficit related to Rhabdomyolysis (A breakdown of muscle tissue that releases a damaging protein into the blood.). The included interventions revised 7/18/22 instructed that Resident #51 needed a hoyer sheet under him on Tuesdays, Thursdays, and Saturday mornings for [CONDITION(S)]. The Care Plan lacked staff directives for monitoring Resident #51's [CONDITION(S)] access site for a bruit, a thrill, bleeding, or other potential adverse problems related to [CONDITION(S)] treatments. The Care Plan lacked instructions regarding performing pre and post [CONDITION(S)] assessments, [CONDITION(S)] center information, emergency contact information, transportation arrangements to and from [CONDITION(S)]. The Nurses Note dated 7/14/22 at 1:14 AM recorded that Resident #51 had [CONDITION(S)] on Tuesday, Thursdays, and Saturdays, with a pick-up time at 9:40 AM. The Progress Notes lacked documentation of assessments of Resident #51's access site or pre and post [CONDITION(S)] assessments. The electronic health record lacked documentation of pre or post [CONDITION(S)] evaluations on 7/12/22 and on 7/16/22. The order summary report dated 7/25/22 documented an order started on 7/19/22 to complete pre and post-[CONDITION(S)] assessments every Tuesday, Thursday, and Saturday related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The July 2022 Medication Administration Records (MAR) recorded pre and post [CONDITION(S)] assessments every Tuesday, Thursday, and Saturday added to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] The July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview 7/17/22 at 3:10 PM, Resident #51 reported he went to [CONDITION(S)] on Tuesdays, Thursdays, and Saturdays. On 7/18/22 at 2:00 PM, the Director of Nursing (DON) gave the self-identification and correction form to the surveyor and reported they had no identified issues of concern. On 7/19/22 at 7:45 AM, the DON confirmed Resident #51 went to [CONDITION(S)] on Tuesdays, Thursdays, and Saturdays. The DON reported the EHR contained the pre and post [CONDITION(S)] assessments under the assessment tab. At the time, the surveyor stated only one pre/post [CONDITION(S)] assessment found dated 7/14/22, but unable to locate pre/post [CONDITION(S)] documentation for dates 7/12/22 and 7/16/22. On 7/19/22 at 1:25 PM, the DON reported she misunderstood what the self identification and correction form was for. She initially told the surveyor they had not identified any problems, but she and the Assistant DON had identified pre and post [CONDITION(S)] assessments not completed the prior week. On 7/26/22 at 10:10 AM, Staff B, Registered Nurse (RN), reported that whenever a resident got admitted to the facility and had [CONDITION(S)], the admission nurse entered orders in the computer for the pre and post [CONDITION(S)] assessments. Staff B stated that the pre and post [CONDITION(S)] assessments were documented in the EHR under the assessment tab, which included the resident's vital signs and weights. The [CONDITION(S)] Process policy revised 7/18 instructed the nurse to document the pre and post [CONDITION(S)] assessment, assessment of the venous access site, vital signs, and weights (if ordered) to assure each resident received care and services for the provision of hemodialysis consistent with professional standards of practice, and to ensure medical information coordinated between the community and [CONDITION(S)] center pre and post [CONDITION(S)].

Based on facility policy review, observations, and staff interviews, the facility did not ensure a sanitary environment for food preparation and storage. At the time of the survey, the facility reported a census of 38 residents that could potentially be affected by this deficient practice. Findings include: During the initial tour on 7/18/22, the RM (Restaurant Manager) showed the main kitchen. The RM said that all food cooked and prepared occurred there before the food got distributed to the units, including the Health Center. Observed the big stand oven's vent with a thick accumulation of dust. Noted four uncovered trays of brisket sat at room temperature on the countertop in the middle of the kitchen. Watched a fly flying around and above an open trash bin, located at the end of the food preparation counter. The facility's dumpster, accessed through the main kitchen's backdoor, had the lid open, exposing the garbage inside. The dumpster's contents almost went to the top, and almost full with flies flying above the dumpster. The main kitchen had two large walk-in refrigerators and one big walk-in freezer, which showed inconsistent temperature monitoring. The Temperature Logs showed multiple areas of blank spots. The July 2022 Temperature Logs lack documentation of temperatures for the two walk-in refrigerators and one walk-in freezer for six out of 18 days for the following dates: 7/1/22, 7/12/22, 7/13/22, 7/14/22, 7/15/22, and 7/18/22. The RM said that those temperatures should be checked twice daily (one in the morning and one in the afternoon) to ensure that food are safe for residents. The facility's undated policy titled, Food Storage provides that food will be stored in an appropriate manner that correlates to its general storage directions. Temperatures of food storage areas are monitored on a daily basis to ensure they are within recommended ranges.

Based on facility record review, facility policy review, and staff interview, the facility failed to ensure the Quality Assurance (QA) and Quality Assurance Performance Improvement (QAPI) committee meetings had the required personnel attend the meetings. The facility reported a census of 38 residents. Findings Include: The review of the QA committe meeting sign-in attendance sheets revealed no Director of Health Center Operations or Administrator attended the meeting held on 8/16/21, 11/10/21, 2/9/22, and 5/10/22. The meeting sign-in sheet also revealed no Medical Director attended the meeting held on 8/16/21 due to being on vacation. The review of the facility's QAPI plan last updated on 3/18/21, revealed the QAPI committee should meet at least quarterly. The team members included: an Administrator, Director of Nursing (DON), Medical Director, Infection Prevention Officer, and other care partners. On 7/26/22 at 11:25 AM, the DON reported they had a provisional administrator since 12/21, but no Administrator or Executive Director attended the QA meetings. On 7/27/22 at 1:00 PM, the Assistant Director of Nursing (ADON)/QA Designee reported that the facility held the QA meetings every month and the Medical Director attended the meetings every quarter. The ADON reported the facility didn't have an Administrator since 6/21, but the facility had a provisional administrator since 3/22 who didn't get involved directly with the day-to-day operations of the health care center. The ADON confirmed that no administrator or Director of Health Center Operations attended the QA meetings. The ADON reported that the staff who attended the QA meeting signed the QA sign-in attendance form.

Based on record review, interviews and review of the facility policy/procedures, the facility failed to provide ongoing assessments and appropriate interventions for a resident with low blood sugar readings (Resident #5). The facility reported a census of 37 residents. The sample consisted of 2 closed records. Findings include: 1.The Patient Discharge & Transfer Form dated 9/22/15 documented Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment with a reference date of 9/27/15, identified Resident #5 had a BIMS (Brief Interview For Mental Status) score of 15. A score of 15 determined the resident had no cognitive problems. The MDS reflected the resident required extensive assistance from staff for bed mobility, transfer, and dressing. The Interim Plan of Care for Resident #5, dated 9/22/15, directed staff to monitor blood glucose levels as ordered by the doctor and to follow the facility ' s low blood glucose protocol as indicated. The Medication Discharge Report signed by the physician 9/21/15 directed staff to administer glimepiride, (oral medication that lowers blood sugar level) 4 milligrams (mg) BID (two times a day), [MEDICATION NAME] (an oral medication that lowers blood sugar) 1000 mg BID. The Physician Standing Orders, signed by the physician on 9/23/15, directed staff to report to the physician if the resident ' s blood sugars are less than 50 or greater than 450, administer [MEDICATION NAME] (an injectable medication that quickly raises blood sugar level) 1 mg IM one time for blood sugar level <50 unless the resident is alert enough to consume food/fluids and may administer one glucose tablet orally PRN (as needed) for blood sugar level <50. The facility's Diabetic Management Protocol revised on 9/30/14, directed the following interventions for [DIAGNOSES REDACTED] (blood sugar level less than 50): Point 1. Test the blood glucose. If less than 50, recheck the blood glucose. Point 2. If the blood glucose remains below 50, give 15 grams of carbohydrates and to choose 1 intervention: 4-6 ounces fruit juice, 3 glucose tablets, 4-6 ounces of soda pop, 8 ounces of skim milk, 3-4 packets of table sugar, 1 tube of (15 ounces) glucose gel. Point 3. Monitor the resident closely. Recheck the blood glucose within 30-60 Minutes, or sooner, if resident condition warrants. Repeat until the blood sugar is noted to be greater than 50. If the blood glucose remains low, notify the physician. Follow any orders/instructions. Point 4. Once stabilized, the resident should receive a snack (peanut butter sandwich and 8 ounces skim milk) or the next scheduled meal if within 30 minutes. Point 5. Update the physician and family of hypoglycemic episode and corrective measures unless otherwise directed by physician orders. The Nurses Notes entry dated 9/26/15 at 5:45 PM documented the resident sweating, clammy and in and out of sleep. The resident's blood sugar measured 40 (normal range is 70-110); The staff administered orange juice with sugar added and crackers with peanut butter. An entry dated at 6:15 PM documented the resident's blood sugar measured 59 and the resident awake and talking. The clinical record did not contain any further assessment of the resident's blood sugar or documentation the physician had been notified. The Medication Administration Record [REDACTED]. The Nurses Notes dated 9/26/15 at 10:00 p.m. indicated the resident ' s daughter had been at the facility much of the evening. The resident sat up and ate supper and ambulated to the bathroom with assistance of 1 staff person and a front wheel walker. The resident received pain medication for the shoulder pain and a nebulizer treatment was given. The resident requested [MEDICATION NAME] for anxiety and he/she informed nurse he/she not ready to lie down to sleep at this time. The resident voiced he/she did not want the C-PAP (for sleep apnea) because of being so worked up to have that ([MEDICAL CONDITION] device) on his/her face. The Nurses Notes dated 9/27/15 at 1:30 a.m. reflected the resident sat on the side of the bed watching television, with the bedside table in front of him/her. At 2:30 AM the staff observed the resident in bed with foam coming out of his/her mouth and respirations labored. The resident had a blood glucose level of 54 and assessed to be nonresponsive. The resident had an oxygen saturation of 58 percent (normal 97-100 percent). Staff suctioned the resident's mouth, placed sugar under the resident ' s tongue and notified 911. The EMS (Emergency Medical Services) report dated 9/27/15 documented the ambulance personnel arrived at the facility at 2:43 AM and found the resident nonresponsive and a blood sugar reading of 54. EMS personnel administered 50% [MEDICATION NAME] solution intravenously. The resident's blood glucose reading rose to 263 at 2:45 AM. The resident transferred to the hospital at 3:26 AM. During an interview on 2/11/16 at 3:14 PM and with the resident's physician, and also the facility's medical director, stated he would expect staff to notify him or the on-call physician if a resident had a blood sugar reading of less than 50 and/or greater than 50 and found non-responsive. The physician would expect a call in addition to staff calling 911. The physician stated he would discuss the current [DIAGNOSES REDACTED] policy with the facility and implement adjustments.

Based on record review, observation and staff, family and resident interviews, the facility failed to provide adequate supervision to ensure against hazards from self and revise the plan of care to ensure the resident ' s safety needs are met for 2 of 4 residents reviewed (Residents #1 and #2). The facility reported a census of 39 residents. Findings include: 1. The Profile Face Sheet for Resident #1 identified the resident had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderately impaired decision making. The MDS revealed Resident #1 required limited assistance of one staff with bed mobility, transfers, dressing, toilet use and personal hygiene. The Care Plan directed the staff to transfer and ambulate, using assistance of one staff, walker and gait belt, poor safety awareness, provide reminders to await assistance and provide with frequent checks. The Resident Incident Report sheet dated 5/8/13 at 6:10 p.m. revealed the staff heard a bang and found Resident #1 on the floor in front of the wheelchair. The sheet revealed an intervention of increased monitoring for immediate action to prevent further injury. The sheet revealed the staff also removed the wheelchair from the room (ambulates with a walker). The Nurse's Notes dated 5/19/13 at 9:00 a.m. revealed Resident #1 wandering and the staff telephoned a family member and explained 1:1 (one to one) redirecting. The staff asked the family to sit with Resident #1. At 10:30 a.m., the family was leaving the facility. The nurse explained to the family member that the resident needed 1 to 1 care. The family told Resident #1 if he/she did not use the call light they would have to get someone to watch him/her. The family told the staff to tell Resident #1 the same if they had problems with noncompliance. At 2:30 p.m., the staff found Resident #1 on the floor. Resident #1 had the left leg under the right leg. The staff notified the family and had Resident #1 transferred to the hospital. The Resident Incident Report sheet dated 5/19/13 at 2:30 p.m. revealed the cleaning staff found Resident #1 on the floor. The sheet revealed Resident #1 fell from the chair and required medical treatment at the emergency room . The comments on the sheet revealed Resident #1's family provided 1 to 1 earlier in the day and social services working with the family to find appropriate placement in a memory care unit. The emergency room (ER) Report Sheet revealed the resident arrived to the ER room at 3:20 p.m. The report indicated the resident experienced pain on a scale of 5 out of 10 at 3:45 p.m. The ER staff administered 50 micrograms of Fentanyl (narcotic analgesic) intravenously. At 4:17 p.m. the resident received another 50 micrograms due to continued pain. At 5:23 p.m. the pain continued to remain at a scale of 5. The staff administered Morphine 4 milligrams intravenously. An x-ray of the left hip revealed Resident #1 sustained a left hip fracture. On 6/20/13 at 10:57 a.m. Staff D (Licensed Practical Nurse-LPN) reported the day of the incident he/she talked to the family about Resident #1 needing increased supervision. Staff D reported the staff provided 1 to 1 (1 person providing supervision to 1 resident ratio) when they had time. The family agreed with 1 to 1 supervision. Staff D emailed the Director of Nursing to let him/her know Resident #1 needed 1 to 1 supervision. Staff D telephoned a float staff to provide 1 to 1 for Resident #1 for an hour and checked on Resident #1 every 20 to 30 minutes. Staff D asked the family if they had someone that could sit with Resident #1. The family visited and took Resident #1 to church and then left. The family told the staff they did not have anyone to sit with Resident #1. On 6/26/13 at 9:17 a.m. the Director of Nursing (DON) was interviewed and reported the facility attempts to provide 1 to 1 (supervision care) but they don't always have enough staff (working). The DON reported the family had to cover the cost of providing 1 to 1 supervision. The current Care Plan dated 5/8/2013 identified the resident at risk to receive an injury regarding a fall due to the resident ' s overall weakness. The Care Plan identified the resident to have a poor safety awareness and non-compliant with recommendations. The goal was for the resident to remain free from an injury regards to a fall that increases the level of care. The approach directed staff to provide the resident with frequent checks. The facility was aware the resident needed someone to supervise the resident at all times. The Care Plan approaches did not address the resident ' s need for the required level of supervision (1 staff to 1 resident). 2. The MDS assessment identified Resident #2 had an admitted to the facility on [DATE]. The Resident had [DIAGNOSES REDACTED]. Resident #2 had severe cognitive ability and rarely made decisions. Resident #2 required extensive assistance of 2 staff for bed mobility, transfers, dressing and toilet use. The resident only walked 1-2 times a week with assistance of 2 staff with the use of a walker and had total dependence of staff for bathing. The Care Plan dated 5/2/13 identified the resident had a problem with falls. The approaches directed staff that the resident required assistance of 1-2 staff up until 6/18/13 which then increased to the assistance of 2 staff for transfers with a walker. The Care Plan directed the staff to utilize a motion sensor alarm on the resident ' s door on 6/171/3. The Incident Report dated 6/16/13 at 11:45 a.m. revealed Resident #2 walked out of his/her room, out the front door and sustained a fall. The incident report indicated the resident received a bump to the head and skin tears to the right elbow. The Nurses Notes dated 6/16/13 at 11:45 a.m. revealed Resident #2 went outside of the facilities front door. The resident sustained [REDACTED]. Review of the Residence Facility Encounter Form dated 6/17/13 completed by the resident's Nurse Practitioner, revealed the resident fell yesterday (6/16/13) and immediately after the fall the staff reported the resident had increased confusion and slurred speech. The Nurse Practioner documented the resident suffered a stroke. On 6/24/13 at 7:45 a.m., Staff A (Licensed Practical Nurse-LPN) was interviewed and stated she worked the dayshift on 6/16/13 and had responsibility for Resident #2. Staff A stated Resident #2 walked out of the front door unattended and the staff did not have knowledge Resident #2 was outside of the facility. Staff A reported a visitor came into the building and notified the staff Resident #2 had fallen outside and needed assistance. During an interview with the Director of Nurses (DON) on 6/18/13 at 4:30 p.m., the D.O.N. stated Resident #2 went outside of the facility without staff knowledge. As an intervention after the elopement, the staff placed a motion alarm on Resident #2's door and completed hourly checks after the resident elopement on 6/16/13. The D.O.N. stated the current alarm system, on the exit doors on 6/16/13, chirped softly , shuts itself off in 15 seconds of being activated and could not be heard out on the unit. The D.O.N. stated the facility is scheduled to have a new alarm system placed on the exit doors in July 2013. The new alarm system will be loud enough to alert the staff when residents exit the doors.

Based on record review, resident and staff interviews and review of the facility policy/procedures, the facility failed to promptly answer the resident ' s activated call light in a time period of no longer than 15 minutes and provide toileting/incontinent care needs for 5 of 7 residents reviewed (Resident #2, #3, #4, #5, #6). The facility identified a census of 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment with a reference date of 8/26/11 reflected Resident #2 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a brief interview for mental status (BIMS) score of 15 out of 15. The MDS identified the resident required extensive assistance from staff with transfers and dressing, occasionally incontinent episodes of bladder and as continent of bowel function. Review of the facilities Interim Care Plan dated 8/19/11, documented the resident required assist of one staff with transfers and ambulation. The care plan identified the resident at a fall risk and required staff assistance with activities of daily living (ADL) and incontinent of bowel at times. Review of the facilities Safety Risk Data Collection form dated 8/19/11, documented the resident had a history of [REDACTED]. Review of the "Auditrak.com" call light system printed 8/30/11 documented the residents call light had been on for more than 15 minutes on the following dates and times. a. On 8/1/11 at 7:35 a.m. the call light was activated and staff responded at 7:53 (18 minutes later). On 8/30/11 at 12:35 p.m., the resident confirmed the staff had not always answered the call light in a timely manner and that there had been times the call light had become disconnected from the facilities call system which disabled the alarm. The resident confirmed there had been times the previous stated instances had caused him/her to become incontinent and have loose stools which did not make him/her fell very good about self. The resident stated there had also been times he/she ambulated to the bathroom by him/herself so would not become incontinent. 2. The MDS assessment with a reference date of 7/8/11 indicated Resident #3 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a brief interview for mental status (BIMS) score of 8 out of 15 and required extensive assistance of staff with transfers, ambulation and toileting. A list of interview able residents provided by the facility dated 8/30/11, documented the resident as interview able. A Bowel and Bladder Evaluation form updated 4/18/11, documented the resident had no change in his/her status of rare episodes of bladder incontinence. A Plan of Care form with a review dated 10/14/11, documented the resident had an area of concern addressed as having a [DIAGNOSES REDACTED]. Interventions included: a. Check on him/her frequently throughout the day and night and provide any needs that his /her family or he /her self may have. Respond to calls or alarms promptly. Review of the facilities Safety Risk Data Collection form dated 4/11/11, documented the resident had a history of [REDACTED]. Review of the "Auditrak.com" call light system printed 8/30/11 documented the residents call light had been on for greater than 15 minutes on the following dates and times: a. On 8/1/11 at 10:35 a.m. the call light activated and did not receive a response until 10:54 a.m. - 19 minutes. b. On 8/2/11 at 2:58 p.m. the call light activated and did not receive a response until 3:23 p.m. (25 minutes later). c. On 8/2/11 at 5:06 p.m. the call light activated and did not receive a response until 5:23 p.m. (17 minutes) later. d. On 8/2/11 at 7:08 p.m. the call light was activated and did not receive a response until 7:25 p.m. ( 17 minutes later) e. On 8/12/11 at 8:16 p.m. the call light was activated and did not receive a response until - 24 minutes. f. On 8/14/11 at 7:07 a.m. the cal light was activated. A response did not occur until 7:47 a.m. (40 minutes). g. On 8/14/11 at 11:50 a.m. the call light was activated and a response did not occur until 12:19 p.m. (29 minutes). h. On 8/14/11 at 7:40 p.m. the call light was activated and a response did not occur until 7:59 p.m. (19 minute). i. On 8/19/11 at 11:05 a.m. the call light was activated and a response did not occur until 11:22 a.m. (17 minutes). j. On 8/22/11 at 2:42 p.m. the call light was activated and a response did not occur until 3:08 p.m. (26 minutes.). k. On 8/24/11 at 9:30 p.m. the call light was activated and a response did not occur until 9:47 p.m. (17 minutes). During a group interview on 8/30/11 at 1 p.m., the resident confirmed his/her call light had not been answered in a timely manner that caused him/her to become incontinent and this did not make him/her feel very good about themselves. The resident also confirmed that staff entered his/her room, turned the call light off and stated would return but did not do so in a timely manner. During an interview 8/31/11 at 12:55 p.m., the resident confirmed he/she had to wait for staff to answer the call light and there had been times had become incontinent and this make him/her feel agitated and embarrassed. The resident stated had felt the facility really needed more staff. 3. A Care Plan dated 9/4/11, documented Resident #4 had an area of concern which identified the resident had come to the care center after a brief hospitalization due to a fall in the assisted living apartment. The resident suffered a T9 compression fracture. The interventions included: a. Assure the call cord had been within reach at all times and respond promptly to any calls from me and assist as needed. Review of the "Auditrak.com" call light system printed 8/31/11 documented the resident ' s call light had been on for more than 15 minutes on the following dates and times: a. On 5/2/11 at 1:19 p.m. the call light was activated and the response time was 1:37 (18 minutes). b. On 5/6/11 at 6:05 p.m. the call light was activated and the response time was 11:17 p.m. (5 hours and 12 minutes). c. On 6/2/11 at 8:23 a.m. the call light was activated and the response time was 8:43 a.m. (20 minutes). 4. The MDS assessment form with a reference date of 7/1/11 indicated Resident #5 had [DIAGNOSES REDACTED]. The MDS documented the resident had a BIMS score of 15 out of 15, continent of his/her bowel and bladder and required extensive assistance of staff with transfers, ambulation, dressing and toilet use. The Care Plan dated 10/5/11, documented the resident had an area of concern with self care deficit related to an old [MEDICAL CONDITION] as evidenced by decreased strength and endurance with left sided weakness which required extensive assistance with his/her activities of daily living (ADL) tasks except eating. Interventions directed staff to: a. The resident usually awakes at least once a night to void. Assist the resident by using one person and a gait belt to pivot transfer to the bedside commode. b. Assure the call cord/pendant was within reach at all times. Respond promptly to any calls from him/her and assist as needed. Review of a Safety Risk Data Collection form dated 7/4/11, documented the resident at a high risk for falls related to a history of falls, [MEDICAL CONDITIONS] late effects, unsteady gait, poor balance and multiple medications. A Bowel and Bladder Function Data Collection and Evaluation form dated 7/4/11, documented the resident with no incontinence. Review of the "Auditrak.com" call light system printed 8/30/11 documented the resident ' s call light had been on for more than 15 minutes on the following dates and times; a. On 8/2/11 at 9:43 a.m. the call light was activated and had a response time of 10:06 a.m. (23 minutes). b. On 8/2/11 at 4:36 p.m. activation occurred had a response time of 23 minutes later (4:59 p.m.). c. On 8/2/11 at 8:49 p.m. activation of the call light occurred with a response at 9:13 p.m. (24 minutes later). d. On 8/5/11 at 9:49 p.m. activation of the call light occurred and response time of 27 minutes later (10:16 p.m.) e. On 8/7/11 at 8:22 a.m. the call light was activated and had a response time of 19 minutes (8:41 a.m.). f. On 8/14/11 at 6:17 a.m. the call light was activated and had a response time of 6:34 a.m. (17 minutes later). g. On 8/17/11 at 2:33 a.m. the call light was activated and had a response time of 2:56 (23 minutes later). h. On 8/17/11 at 8:51 a.m. the call light was activated and had a response time of 9:12 a.m. (21 minutes later). j. On 8/19/11 at 9:37 a.m. the cal light was activated and had a response time of 9:55 a.m. (18 minutes later). k. On 8/20/11 at 11:19 a.m. the call light was activated and had a response time of 2:12 p.m. (2 hours and 53 minutes later). l. On 8/22/11 at 2:48 p.m. the call light was activated and the response time was 3:09 p.m. (21 minutes later). m. On 8/22/11 at 8:17 p.m. the call light was activated and the response time was 8:34 p.m. (17 minutes later). n. On 8/23/11 at 7:01 a.m. the call light was activated and the response time was 7:26 a.m. (25 minutes later). o. On 8/25/11 at 11:31 a.m. the call light was activated and had a response time of 11:49 a.m. (18 minutes). During a group interview on 8/30/11 at 1 p.m., the resident confirmed there had been times staff did not answer his/her call light when he/she had been on the toilet for 40 minutes to 1 hour which caused his/her lower extremities to become tingly and his/her feet blue in color. The resident also confirmed staff had left him/her on the commode at bedside without a call light, pendent alarm device and/or his/her telephone. During a group interview 8/30/11 at 1 p.m., the resident confirmed the staff did not answer his/her call light in a timely manner which caused him/her to become incontinent which caused embarrassment. 5. A MDS assessment dated [DATE]; documented Resident #6 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a BIMS score of 15 out of 15, frequently incontinent of his/her bladder and occasionally incontinent of his/her bowel and required extensive assistance of staff with transfers and toilet use. A Safety Risk Data Collection form dated 8/1/11, documented the resident at a high risk for falls related to a history of falls, MS, [MEDICAL CONDITION] and weakness. A Bowel and Bladder Evaluation form updated 7/29/11, documented the resident as occasionally incontinent with a precipitating factor as waiting too long. Review of the "Auditrak.com" call light system printed 8/30/11 documented the residents call light had been on for more than 15 minutes on the following dates and times. a. 8/8/11 at 7:18 a.m. - 7:18 a.m. - 19 minutes. During a group interview 8/30/11 at 1 p.m., the resident confirmed the staff did not answer his/her call light in a timely manner which caused him/her to become incontinent which caused embarrassment. During an interview 8/31/11 at 11:15 a.m., Staff A, certified nursing assistant, confirmed there had been times the staff had not been able to answer call lights within 15 minutes which had caused residents who had normally been continent to become incontinent and that these residents verbalized to him/her that they had been embarrassed. Review of the facilities "Call Light, use of" policy and procedure dated 2008, documented the purpose had been to respond promptly to residents call for assistance and to assure the call system had been in proper working order. The procedure included the following directives: a. All facility personnel must be aware of call lights at all times. b. Answer ALL call lights promptly whether or not you are assigned to the resident. c. When providing care to residents are sure to position the call light conveniently for the resident to use. Tell the resident where the call light had been and show him/her how to use the call light. d. Check all call lights daily and report any defective call lights to the nurse immediately. e. Be sure the call lights are placed within resident reach at all times, never on the floor or bedside stand.

Based on clinical record review, facility policy review, staff, family and physician office staff interviews, the facility failed to assess and provide timely interventions for one of five residents (Resident #1) reviewed that had a urinary tract infection [MEDICAL CONDITION]. The facility census was 38 residents. Findings include: 1. A history and physical report, documented Resident #1 had been admitted to the hospital from home on 5/18/11 with a [MEDICAL CONDITION]. The report indicated the resident also had [DIAGNOSES REDACTED]. An interim care plan dated 6/24/11 indicated the facility admitted the resident from the hospital for skilled care with a plan to discharge the resident back home with his/her family. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 demonstrated long and short term memory problems and moderately impaired skills for daily decision making. The MDS further indicated Resident #1 required extensive assistance with transfers, dressing and toilet use, and limited assistance with eating. However, the resident's Interim Care Plan dated 6/24/11 identified the resident needed total staff assistance with eating and hydration, with an approach to encourage fluids at meals, medication pass and between meals. A Bowel and Bladder Evaluation dated 6/28/11 identified the resident demonstrated an alteration in fluid intake: Sometimes s/he refused the offer of fluids and seldom asked for fluids. The resident required total feeding/oral assistance. The Care Area Assessment Summary dated 7/6/11 showed Resident #1 triggered for dehydration/fluid maintenance and that this would be addressed in Resident #1's care plan. The narrative dated 7/7/11 documented Resident #1 triggered for dehydration/fluid maintenance due to having a urinary tract infection within the last 30 days. The note documented Resident #1 currently showed no signs or symptoms of fluid overload or dehydration, and that staff and family members encouraged the resident to drink fluids. A physician order [REDACTED]. These two medications are diuretics which remove fluid from the body and place elderly residents at risk for dehydration according to the facility's drug reference guide. The Care Plan for Medicare Part A Residents returning Home dated 7/7/11, did not identify the resident as at risk for dehydration/fluid maintenance, of approaches that should be implemented to decrease risk, or of what signs and symptoms to observe for. An admission Nutritional Evaluation History and Data Collection form identified Resident #1 required 1,786 to 2,382 cubic centimeters (cc's) of fluid per day. A meal and fluid detail report dated 6/28/11 to 7/12/11 documented Resident #1's fluid intake as follows: a. 6/28/11 at 9:47 a.m.- 400 cc's. b. 7/6/11 at 10:46 a.m.- 240 cc's. c. 7/8/11 at 10:06 p.m.-100 cc's. d. 7/10/11 at 11:42 a.m.- 240 cc's. No other indication of Resident #1's fluid intake could be found in the clinical record. A Daily Skilled Nurse Note dated 7/11/11 at 9:00 a.m., documented Resident #1 slept most of the time, that staff had assisted the resident with all activities of daily living (ADLs), and that the resident had fed self partially with much encouragement. The note indicated the resident had been incontinent and did not ask to use the bathroom. At 3:30 p.m., the note reflected staff had straight cathed (inserted a tube into the resident's bladder through the urethra) the resident to obtain a urine specimen. The specimen appeared cloudy, pus-like, and had a foul odor. According to the note, staff sent the specimen directly to the physician's office and notified the family, who were at the facility, of these actions. At 4:50 p.m., staff attempted to call the physician's office for antibiotic orders. An entry at 6:00 p.m. indicated the resident's family member (who was at the facility) had called the resident's personal physician requesting an antibiotic order. The on-call physician then returned the staff's call who informed him/her of the antibiotic order the resident's personal physician had given. The note did not include any information regarding the resident's skin turgor, mucous membranes, or temperature. Nurse notes dated 7/12/11 at 10:45 a.m., documented Resident #1's family had placed a call to the resident's personal physician to report the resident had a possible urinary tract infection [MEDICAL CONDITION] and decreased cognition and appetite. Per the family, the physician had recommended the resident be transferred to the emergency room due to the resident's history of UTIs with dehydration. The note further stated Resident #1 had a urinalysis with culture and sensitivity pending per another physician's orders [REDACTED]. The clinical record lacked documentation the facility had assessed the resident's condition for signs/symptoms related to urinary tract infections or dehydration prior to or after obtaining an order to collect a urine specimen, obtaining an antibiotic order, and obtaining an order to transfer the resident to the emergency room . The discharge summary dated 7/12/11 stated the facility discharged the resident to the hospital for treatment of [REDACTED]. The report indicated the resident had exhibited a poor appetite. A facsimile (fax) communication dated 7/12/11, from the facility to the facility's physician documented the resident had a UTI, had been started on [MEDICATION NAME] (an antibiotic) orally, with a history of UTI with dehydration. The fax noted the resident had decreased cognition, appetite, and oral intake. The fax noted an order an been received to transfer the resident to the emergency room for treatment of [REDACTED]. A History and Physical report dated 7/12/11, documented Resident #1 had a very bad urinary tract infection, was very dehydrated, and had acute [MEDICAL CONDITION] superimposed on his/her chronic [MEDICAL CONDITION] and [MEDICAL CONDITION] (high blood potassium level). The report indicated 2 family members reported Resident #1 had not eaten or drank for 3 days. The physical exam revealed the resident's systolic blood pressure measured in the mid 90's and that the resident had already received 1 liter of fluid in the emergency room . The report stated the resident exhibited dry mucous membranes and that the urinalysis was consistent with urinary tract infection, with cultures pending. The resident's blood laboratory results revealed a potassium of 6.3 (high), BUN 78 (high), and creatinine up to 5.8 from 2.1 (high). Resident #1's [DIAGNOSES REDACTED]. Resident #1's treatment plan included intravenous fluids, antibiotics, and a hold of his/her blood pressure medications. An Interdisciplinary Discharge Assessment and Summary dated 7/12/11, documented a recapitulation of Resident #1's stay which included: He/she needed total assist, he/she exhibited occasional behavior with cares, poor appetite/nutrition, and refused medications at times. Resident #1's family at the facility most times to assist with cares and to encourage resident. The family wanted to take him/her home for comfort. Resident #1 had a current urinary tract infection. The 24 Hour Report Sheet dated 7/11/11, indicated on the night shift staff turned and repositioned the resident every 2 hours, and was on a list for discharge on 7/13/11. On the day shift, Resident #1 had no complaints, was incontinent, and dependent on staff for all activities of daily living. The evening shift noted indicated the resident had a UTI with an antibiotic started and that the resident hadn't eaten. The 24 Hour Report Sheet dated 7/12/11, indicated on the night shift that the resident had a temperature of 98.3 degrees Fahrenheit (F), that the resident was on an antibiotic for a UTI, and that his/her urine was clear with no odor. The note stated the resident wasn't drinking and questioned if the family was going to take him/her to the hospital today. The day shift indicated the resident had transferred to the hospital. During interview on 7/27/11 at 9:27 a.m., the resident's personal physician's office nurse stated the facility staff did not agree with the physician that the resident should have been sent to the hospital. She further indicated the resident had been admitted to the hospital with [REDACTED]. During interview on 7/27/11 at 3:41 p.m., Staff B, Registered Nurse (RN), stated she had cared for Resident #1 (on 7/11/11). Staff B stated she had given report to Staff G, RN, who later collected a urine sample from Resident #1. Staff B stated Staff G brought the specimen over to her and it looked like milk to her. Staff B stated she felt they should get a urine specimen, because the resident wasn't acting right. Staff B stated they were kind of busy that day but that she had taken Resident #1's temperature. When informed a temperature had not been charted, Staff B stated she thought she had taken it, but maybe she had just felt the resident's forehead with the back of her hand. Staff B stated if it wasn't charted she couldn't say for sure she did it. Staff B stated she worked the day shift and Resident #1 had eaten/drunk normally. Staff B stated they monitored Resident #1's intakes, but hadn't monitor how much, so she didn't know how much fluid Resident #1 had consumed. Staff B stated when a resident had a UTI or was on an antibiotic, they would check that resident's temperature every shift. They would monitor resident's conditions and make sure they were drinking. Staff B stated as long as residents urinated, they must be drinking. Staff B stated she did not know how much Resident #1 had urinated, but knew that he/she did. Staff B stated Resident #1 did not feel well that day and the family told her the resident had a history of [REDACTED]. During interview on 7/27/11 at 3:36 p.m., Staff G, RN, stated she had worked the evening of 7/11/11 and obtained a urine sample from Resident #1. Staff G stated a CNA from the day shift had reported to the day shift nurse that Resident #1 had cloudy, odorous urine. Staff G stated Resident #1's urine looked like yellow milk. Staff G stated Resident #1's family made him/her drink. Resident #1 didn't feel well that day and didn't drink much that night. Staff G did not know Resident #1's intakes. Staff G stated they didn't keep track of the resident's I & Os. Staff G stated they could have asked the family how much the resident drank. Staff G stated the CNAs always filled the water glasses. Resident #1 demonstrated combative behaviors and preferred the family to assist him/her. Staff G stated when a resident had a UTI, they would check the resident's temperature and fluid intakes. Staff G stated they only needed to do a full assessment 1 time every 24 hours when a resident received skilled care. During interview on 7/28/11 at 10:00 a.m., Staff E, RN, stated she really didn't recall receiving any report about Resident #1 having a UTI. After thinking about it, she recalled the family voicing the resident needed more fluids. Staff E stated during the night shift, they checked and changed the resident's brief every 2 hours and offered water. Resident #1 took maybe a sip of water. Staff E was unsure how many incontinent episodes Resident #1 had that night. Staff E stated she did not do an assessment on Resident #1, but she supposed she could have. Staff E stated if a resident had a UTI she would check the resident's temperature, urine color and odor, and encourage the resident to drink fluids. Staff E stated she didn't know if they had established Resident #1 had a UTI at that point. Staff E stated that if a resident was dehydrated she would check skin turgor, blood pressure, pulse, and general appearance. She didn't think dehydration was a problem for Resident #1. Staff E stated she only documented unusual findings. During interview on 7/28/11 at 9:24 a.m., Staff D, LPN (licensed practical nurse), stated that during report on 7/12/11, the night nurse stated Resident #1's family wanted him/her to go to the hospital for intravenous antibiotics. When the resident's family came in they asked her how to get Resident #1 to the hospital. Staff D told them they could call the ambulance service. Staff D then went to get the Director of Nursing, and Staff C, because she was fairly new and wasn't sure exactly what to do. Staff D stated she thought the resident's family had called the resident's personal physician while Staff C called the medical director. Resident #1's family member seemed very upset. Staff D stated that when she was in Resident #1's room that morning, she noted the resident as a little more lethargic than usual. Staff D did not do an assessment of Resident #1's condition at that time. When Resident #1's family arrived on 7/12/11, they asked her if Resident #1 had had anything to drink as yet, and Staff D had told them no. Resident #1's family stated that the resident had not drunk anything for 2 days. Staff D stated she then let Staff C take over (assisting the family). Staff D stated when a resident had a UTI, she would check his/her urine, encourage fluids and ensure staff provided proper peri care. Staff D stated they could have asked the family what Resident #1 drank. During interview on 7/28/11 at 11:24 a.m., Staff C, MDS Coordinator, stated that on the day Resident #1 transferred to the emergency room , a CNA had reported to her that the resident's family had called their personal physician to facilitate the resident's transfer to the hospital. Staff C made arrangements to send the resident to the hospital. Staff C stated she had not assessed Resident #1, she had only obtained an order (to transfer) him/her. Staff C stated she did not take Resident #1's vital signs because she thought they were on the vitals' sheet. Staff C agreed the record lacked documentation of Resident #1's condition. Staff C stated that when a resident had a UTI they should check his/her temperature every shift, assess the resident's urine, and encourage fluids. During interview on 7/27/11 at 8:06 a.m., Staff A, RN, stated Resident #1's family assisted the resident with meals and fluids. Staff A stated staff could have checked Resident #1's the amounts left in the resident's glasses or asked the family how much he/she drank. Staff A did not know why the resident's fluid intakes were not documented more often than they were. Staff A stated an assessment for dehydration would be limited to checking a resident's skin and oral mucous membranes. When discussing the family's call to the physician regarding the resident's condition, Staff A stated they were aware Resident #1 was declining and had a bad UTI. On 7/27/11 at 4:32 p.m., Staff A agreed staff should have assessed Resident #1's condition every shift after they discovered the UTI, including the amount and characteristics of the resident's urine output and amount of fluids the resident drank. During interview on 07/27/11 at 10:55 a.m., one of Resident #1's family members stated the facility staff did not ask them what Resident #1 ate or drank when the family member assisted the resident at meal times. During interview on 7/27/11 at 11:05 a.m., another one of Resident #1's family members stated he/she assisted Resident #1 a great deal at the facility. The family member stated that occasionally, at the end of the day, a staff member would ask him/her if the resident had eaten or drunk anything, and that he/she would respond "no." During interview on 7/28/11 at 9:13 a.m., Staff F, MDS Coordinator, stated she had reviewed Resident #1's care plan and had overlooked care planning the resident's risk of dehydration. Staff F stated she should have added the following interventions: a. Encourage fluids. b. Monitor and assure access to fluids. c. Dietary to find out Resident #1's fluid preferences and assure available. d. Nursing to monitor to assure taking adequate fluids. e. Weights if ordered. f. Assess mucous membranes, skin turgor, [MEDICAL CONDITION]. Staff F stated that she hadn't actually physically assessed the resident on 7/07/11 when she completed the CAA assessments, but had received her information from record review, and staff and family interviews. The facility's hydration policy dated 7/20/09 indicated each resident would be provided with sufficient fluids to maintain proper hydration and health. Each resident's fluid needs would be determined by the dietetics professional upon admission. Each resident would be evaluated for risk factors for dehydration during the initial nutrition assessment, including coma/diminished sensory capacity, fluid loss, increased fluid needs, functional impairments that make it difficult to drink, reach fluids, or communicate needs, dementia in which resident forgets or refuses fluids. Nursing staff would monitor residents for physical signs of dehydration, i.e., sunken eyeballs, concentrated urine, poor skin turgor, etc. and communicate the signs and or symptoms of dehydration to the dietetics professional who would then reassess the fluid status of the resident. The facility reference cards directed charting must reflect: a. What is being observed and assessed. b. Daily observation and assessment. c. Appropriate response to what is observed. d. Lack of response would jeopardize the resident's medical safety. Urinary tract infection: a. Frequency, urgency, burning. b. Temperature. c. Increased fluid intake. d. Chills. e. Nausea. f. Vomiting. g. Blood/pus in urine. h. Pain in bladder region/back. i. Malaise (feeling of illness). j. Headaches. Voiding pattern a. Urine color, odor. b. Level of alertness. c. I & O. Daily charting must reflect evidence that nurse's/therapists were assessing or supervising results of care that is given by non-skilled personnel and verifying that care is furnished.