Every finding on record at Edgewood Place at the Village at Brookwood

Based on observations, record review, and staff interviews, the facility failed to keep food preparation areas and food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. In addition, the facility failed to clean the ceiling vents located over the food preparation and food service areas. These practices had the potential to affect food served to residents. The findings included:During a kitchen tour on 7/21/25 at 10:44 AM, the following observations were made with the kitchen Supervisor and Dining Service Director:a. Stove #1 had six (6) burners that had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were large amounts of burnt food, dried, encrusted, liquid splatters throughout the stove area.b. Stove #2 had twelve (12) burners that had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were large amounts of burnt foods, dried, encrusted, liquid and splatters throughout the stove area.c. The two plate warmers had two rows of clean plates stored inside the warmer. The inside of warmer had dried liquid spills and food particles inside and dried liquid spills on the outside. The inside also had old food crumbs all around.d. The deep fryer had dried brown/yellow matter encrusted on the inside and outside edges. The fryer had heavy grease and food build-up inside and outside the unit and food particles were observed behind the fryer.e. The 15 ceiling vents had large volumes of black dust/debris blowing over blowing over the steam table, clean dry dishware storage racks, food service and preparation surfaces.f. The inside and outside of the hot box had dried food and liquids.g. The floors under the stoves, oven, prep tables, steam tables were dirty, sticky with old food debris.An interview was conducted on 7/21/24 at 11:18 AM, Kitchen Supervisor and Dining Service Director stated the kitchen staff were required to wipe down kitchen equipment after each meal and deep cleaned weekly in accordance with the kitchen cleaning checklist. The Dining Service Director and Kitchen Supervisor further stated they were responsible for ensuring the kitchen staff kept the equipment clean and orderly. The Dining Supervisor and Kitchen Supervisor acknowledged the identified kitchen equipment, ceiling vents had not been cleaned in accordance with the checklist. The Kitchen Supervisor stated all cleaning checklists and responsibilities would be updated and available for all kitchen staff. Review of the undated kitchen checklist provided on 7/22/25 revealed cleaning and wiping down steam tables, sweeping/mopping floors, cleaning refrigerators and meal carts. There was no indication on the checklist that the identified kitchen equipment was deep cleaned or just wiped down. An interview was conducted on 7/22/25 at 12:27 PM with Dining Service Director stated the cleaning checklist was done on a 5-week schedule which included a variety of cleaning tasks for the kitchen equipment. He stated once the weekly cleaning list was completed and checked by the Kitchen Supervisor and himself the information was discarded. He stated he did not have any documentation for the cleaning checklist for the past 5 weeks. The Dining Service Director confirmed the identified observations of the kitchen equipment, and the ceiling vents needed to be cleaned. He also stated the staff were expected to clean the kitchen equipment in accordance with the kitchen checklist. He reviewed the current kitchen checklist and confirmed there were no specific areas for staff to sign off and the responsibilities were completed after each shift. He further stated there should not be any heavy buildup of grease or dried debris on kitchen equipment. The Dining Service Director further stated he was responsible for ensuring the kitchen staff kept the equipment clean and orderly. He indicated he would be adding the cleaning of the kitchen vents to the newly developed checklist and maintaining records weekly.A follow-up observation in conjunction with an interview was conducted on 7/24/25 at 11:25 AM with the Director of Dining Service who stated all the identified areas on 7/21/25 were currently being worked on and a deep cleaning checklist for kitchen equipment and the vents will be developed immediately.An interview was conducted on 7/2/24 at 12:10 PM, the Administrator stated the Kitchen Supervisor and Dining Service Director were responsible for ensuring the kitchen was cleaned and maintained. The Administrator stated the expectation would be for the Kitchen Supervisor and Dining Service Director to ensure all kitchen cleaning protocols were in place and followed in accordance with kitchen sanitation guidelines.

Based on record review, and resident, staff, and hospice interviews, the facility failed to honor residents' bathing preference and preferred number of showers per week for 2 of 3 residents (Resident #20 and Resident #11) reviewed for choices. The findings included: 1. Resident #20 was admitted to facility 2/11/20 with a diagnoses that included, venous insufficiency (peripheral) improper functioning of the vein valves in the leg that can cause swelling, muscle weakness, chronic kidney disease and difficulty walking, The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #20 was cognitively intact, had no rejection of care behaviors and was totally dependent on one person for bathing. The MDS further indicated it was very important for Resident #20 to choose between a tub bath, shower, bed bath or sponge bath. Resident #20 also received hospice care while at the facility. A review of the undated facility shower schedule revealed Resident #20 was scheduled for a shower on Tuesday and Thursday by a hospice aide on day shift and Monday and Thursday by the facility. A review of the bathing record for Resident #20 documented that the facility provided partial bed bath every day from 2/25/23 through 3/4/23. On 2/28/23 at 12:58 PM an interview with Resident #20 revealed he used to be taken to the shower room but now he only got bed baths and he didn't know why. Resident #20 stated he preferred showers over bed baths and had told the staff on admission and a couple of other times, but he couldn't remember when. On 3/2/23 at 8:55 AM, an interview with Nurse #2 revealed that the facility staff no longer gave baths or showers to Resident #20 due to hospice being responsible for giving them. Nurse #2 stated that hospice staff gave him baths on Tuesdays and Thursdays. The facility staff only provided a complete bath if Resident #20 required one. However, Resident #20 receives partial bed baths daily from facility staff. Nurse #2 further stated that she knew Resident #20 only liked to have showers and that his preferences were given to hospice upon admission to hospice services. On 03/02/23 at 12:00 PM an interview with the Hospice Nurse Aide revealed she only gave bed baths per Resident #20's hospice care plan. On 3/2/23 2:34 PM, a phone interview with the Hospice Nurse who took care of Resident #20 revealed that hospice provided only bed baths to the residents receiving hospice services due to weakness. The hospice nurse stated they did not evaluate the residents to determine if they could tolerate being given showers and that they only provided bed baths to their residents. An interview with the Director of Nursing (DON) was completed on 3/2/23 at 2:34 PM. DON stated Resident #20 would need to be assessed to ensure that he could safely have a shower. The DON stated facility staff could assist hospice staff with resident showers. The DON explained her goal would be for Resident #20 to receive his showers as requested/per his choice. The DON expressed that communication between hospice staff and facility staff needs to be better. 47810 2. Resident #11 was admitted to facility on 8/18/21. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated that it was very important for Resident #11 to choose between receiving a tub bath, shower, bed bath, or sponge bath. The quarterly MDS assessment dated [DATE] indicated that Resident #11 was cognitively intact and had no rejection of care behaviors. Resident #11 required extensive physical assistance from two persons during bathing. A review of the undated facility shower schedule revealed Resident #11 was scheduled for a shower on Tuesdays and Thursdays on the day shift. A review of the Bathing Record for Resident #11 from 2/14/23 to 3/2/23 revealed he received a shower on 2/14/23 (Tuesday), 2/15/23 (Wednesday), 2/21/23 (Tuesday), 2/23/23 (Thursday), 2/28/23 (Tuesday) and 3/2/23 (Thursday). A review of Resident #11's nursing progress notes from 12/28/22 to 2/28/23 in his electronic health record showed no documentation of shower refusals. An interview with Resident #11 on 2/28/23 at 11:58 PM revealed that he only received showers twice a week on Tuesdays and Thursdays since he had been admitted at the facility. Resident #11 stated he preferred to have showers three times per week. Resident #11 stated that he had spoken to the Administrator a couple of weeks ago but had not heard back from her with an update. An interview with Nurse #1 on 3/3/23 at 10:45 AM revealed that she had been unaware that Resident #11 wanted an extra shower day and that if she had known about it, she would have spoken to the Nurse Manager to get the resident's shower schedule updated. An interview with Nurse Aide (NA) #3 on 3/3/23 at 10:50 AM revealed that she didn't know about Resident #11's request to receive an additional day for a shower. NA #3 stated that if a resident wanted to make any changes to their bathing schedule, she would notify the nurse and the Nurse Manager so the shower schedule would be updated accordingly. An interview with the Nurse Manager on 3/3/23 at 10:55 AM revealed that if a resident wanted to make updates to their bathing schedule, then the facility would try to honor each resident's preference. The Nurse Manager stated that Resident #11 had spoken to her about a week ago that he wanted an extra shower day but she forgot to update the shower schedule then so she would go ahead and update it now. An interview with the Director of Nursing on 3/3/23 at 2:15 PM revealed that she had been unaware of Resident #11's request to update his shower schedule. The DON stated that if there was an issue with bath schedules staff would need to let her know. The DON further stated the Nurse Manager usually assessed the residents for shower preferences on admission and at least quarterly when assessments were due. An interview with the Administrator on 3/3/23 at 2:20 PM revealed that she had spoken with Resident #11 a couple of weeks ago, but he did not want changes made to his shower schedule at that time. She stated that she had informed the resident to let staff know of any preferences and if he wanted to change his shower days. The interview further revealed residents were assessed on admission and then quarterly and then whenever they wanted a change in shower days, they would let staff know and the schedule would be updated.

Based on record reviews and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A skilled services to 2 of 2 residents reviewed for beneficiary notification review (Residents #4 and #6). The findings included: 1. Resident #4 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter was issued and signed by Resident #4 on 10/10/22. The letter explained Medicare Part A coverage for skilled services would end on 10/12/22. Resident #4 remained in the facility at the time the survey was being conducted from 2/28/23 through 3/3/23. A review of the medical record revealed a CMS-10055 SNF-ABN (Skilled Nursing Facility Advanced Beneficiary Notice) was not provided to Resident #4 or their Responsible Party. On 3/2/23 at 2:00 pm an interview was completed with the Business office Manager (BOM). The BOM confirmed they issued the CMS-10123 NOMNC once notified of Resident #4 Medicare Part A coverage for skilled services was ending. The BOM stated that they were unaware the CMS-10055 SNF-ABN was also required for a resident remaining in the facility. The BOM confirmed that neither Resident #4 nor Resident #4's Responsible Party was issued a CMS-10055 SNF-ABN prior to Medicare Part A services ending. An interview was completed with the Administrator on 3/2/23 at 3:52 pm. She revealed that when a resident was coming off Medicare Part A services and the resident had days remaining a SNF-ABN should be issued. 2. Resident #6 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter was issued and signed by Resident #6 on 1/23/23. The letter explained Medicare Part A coverage for skilled services would end on 1/25/23. Resident #6 remained in the facility at the time the survey was being conducted from 2/28/23 through 3/3/23. A further review of the medical record revealed a CMS-10055 SNF-ABN (Skilled Nursing Facility Advanced Beneficiary Notice) was not provided to Resident # 6 or their Responsible Party. On 3/2/23 at 2:00 pm an interview was completed with the Business office Manager (BOM). The BOM confirmed they issued the CMS-10123 NOMNC once notified of Resident #6 Medicare Part A coverage for skilled services were ending. The BOM stated she was unaware the CMS-10055 SNF-ABN was also required for a resident remaining in the facility. The BOM confirmed that neither Resident #6 nor Resident #6's Responsible Party was issued a CMS-10055 SNF-ABN prior to Medicare Part A services ending. An interview was completed with the Administrator on 3/2/23 at 3:52 pm. She revealed that when a resident was coming off Medicare Part A services and the resident had days remaining a SNF-ABN should be issued.

Based on record review and staff interviews, the facility failed to revise the care plan after two falls for 1 of 3 residents (Resident #17) reviewed for falls. The findings included: Resident #17 was admitted on [DATE] with the most recent re-admitted [DATE] with diagnoses of unsteadiness on feet, history of falling, difficulty in walking and muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #17 was moderately cognitively impaired. Resident #17 required limited assistance with transfer and extensive assistance with walking Her balance during transitions and walking was not steady and she was only able to stabilize with staff assistance. Resident #17 was frequently incontinent of bladder and required extensive assistance of one with toileting. The MDS further indicated that Resident #17 had two or more falls with no injury since the prior assessment. Resident #17's care plan last reviewed on 2/1/23 indicated Resident #17 was at risk for falling related to impaired mobility with self-care deficits, cognitive impairment and falls history. Interventions included to toilet resident between 5-7 AM., provide toileting assistance frequently, put shoes on first thing in the morning when Resident #17 got dressed, frequent rounding for safety, call don't fall sign placed in view, administer medication as ordered and observe response and for side effects, assist to keep environment well-lit and free of clutter, assist with appropriate footwear to prevent slipping, encourage resident to assume a standing position slowly, encourage resident to use environmental devices, place bed in lowest position when care complete, place call light within reach, place personal items and frequently used items within reach, provide activities of daily living and mobility assistance as needed, provide verbal cues and reminders for safety and direction as needed. A review of the Observation Detail List Reports for Resident #17 indicated: 1/27/23 - Nurse #3 noted resident had an unwitnessed fall in the dining room with no injury noted. Nurse #3 marked interventions to place resident in common area during time of wakefulness and to engage in activity. 2/25/23 - Nurse #4 noted resident had an unwitnessed fall in the bathroom with no injury noted. Nurse #4 marked an intervention of toileting schedule initiated. A phone interview with Nurse #3 on 3/3/23 at 9:27 AM revealed the Nurse Manager should review all the notes and incident reports so she could update the care plan. Nurse #3 stated the nurses passed along in report about Resident #17's fall on 1/27/23 and they tried to keep her at the nurses' station to keep an eye on her and she relayed to other staff members to watch her. A phone interview with Nurse #4 on 3/3/23 at 1:22 PM revealed she just told the nurse aides about placing Resident #17 on a toileting schedule which was what she marked as a new intervention whenever she fell on [DATE]. Nurse #4 stated she assumed the Nurse Manager read the incident reports and that she updated the care plans after each fall. An interview with the Nurse Manager on 3/3/23 at 2:00 PM revealed she was responsible for updating the care plans and she usually looked at the reports and nursing notes daily. The Nurse Manager stated she did not update Resident #17's care plan after she fell on [DATE] and 2/25/23 and could not recall any interventions that were implemented for those falls. An interview was completed with the Director of Nursing on 3/3/23 at 2:51 PM. She stated that Resident #17's care plan should have been updated with interventions after each fall.

Based on record review and resident and staff interviews, the facility failed to assess a resident for injury before being moved after a fall for 1 of 3 residents (Resident #17) reviewed for falls. The findings included: Resident #17 was admitted on [DATE] with the most recent re-admitted [DATE] with diagnoses of unsteadiness on feet, history of falling, difficulty in walking and muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #17 was moderately cognitively impaired. Resident #17 had no rejection of care behaviors and required limited assistance with transfer and extensive assistance with walking in the room and locomotion on unit. Her balance during transitions and walking was not steady and she was only able to stabilize with staff assistance. Resident #17 had no impairments in range of motion to both upper and lower extremities. The MDS further indicated that Resident #17 had two or more falls with no injury since the prior assessment. Resident #17's care plan last reviewed on 2/1/23 indicated Resident #17 was at risk for falling related to impaired mobility with self-care deficits, cognitive impairment and falls history. Interventions included to provide toileting assistance frequently, frequent rounding for safety, call don't fall sign placed in view and assist to keep environment well-lit and free of clutter. A review of the Observation Detail List Report dated 2/9/23 indicated Resident #17 fell in the bathroom. Nurse #5 wrote CNA (Certified Nursing Assistant) stated she fell in the bathroom, and I got her up. Resident #17 denied any pain. No apparent injury noted. Resident #17 stated she was doing what she wasn't supposed to do. Nurse #5 encouraged Resident #17 to use call bell for assistance. An interview was conducted by phone with Nurse #5 on 3/2/23 at 7:25 PM. Nurse #5 stated that the Nurse Aide (NA) #2 had come to her and told her that Resident #17 had fallen in the bathroom and that she had gotten her up and put her in the bed. Nurse #5 then went to Resident #17's room and did a complete assessment and did not note any injury. Nurse #5 also told NA #2 to always let a nurse assess a resident's condition for injury prior to moving them after a fall. A phone interview was conducted with NA #2 on 3/3/23 at 2:00 PM. NA #2 stated she could not recall the incident regarding Resident #17's fall but she knew she was not supposed to move a resident after a fall without notifying the nurse first. An interview completed with the Director of Nursing on 3/3/23 at 2:51 PM revealed she was not aware of Resident #17's fall incident on 2/9/23 but the nurse aide should have gotten the nurse prior to moving her after she fell .

Based on record review and resident and staff interviews, the facility failed to implement an intervention after a fall for a resident with a history of falls for 1 of 3 residents (Resident #17) reviewed for accidents. The findings included: Resident #17 was admitted to the facility on [DATE] with the most recent re-admitted [DATE] with diagnoses of unsteadiness on feet, history of falling, difficulty in walking and muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #17 was moderately cognitively impaired. Resident #17 had no rejection of care behaviors and required limited assistance with transfer and extensive assistance with walking in the room and locomotion on unit. Her balance during transitions and walking was not steady and she was only able to stabilize with staff assistance. Resident #17 had no impairments in range of motion to both upper and lower extremities. The MDS further indicated that Resident #17 had two or more falls with no injury since the prior assessment. Resident #17's care plan last reviewed on 2/1/23 indicated Resident #17 was at risk for falling related to impaired mobility with self-care deficits, cognitive impairment and falls history. Interventions included to toilet resident between 5-7 am, provide toileting assistance frequently, put shoes on first thing in the morning when Resident #17 got dressed, frequent rounding for safety, call don't fall sign placed in view, administer medication as ordered and observe response and for side effects, assist to keep environment well-lit and free of clutter, assist with appropriate footwear to prevent slipping, encourage resident to assume a standing position slowly, encourage resident to use environmental devices, place bed in lowest position when care complete, place call light within reach, place personal items and frequently used items within reach, provide activities of daily living and mobility assistance as needed, provide verbal cues and reminders for safety and direction as needed. A review of the Observation Detail List Report dated 2/25/23 filled out by Nurse #4 indicated Resident #17 was observed on the floor in the bathroom sustaining no injury and a toileting schedule was initiated. A review of the Observation Detail List Report dated 2/28/23 filled out by Nurse #4 indicated that Resident #17 was observed on floor in her room. Resident #17 was in front of a chair facing her recliner sitting up on her bottom. Nurse #4 noted bruising to Resident #17 left hip/buttock. The intervention marked by Nurse #4 was a toilet schedule was initiated. An x-ray was obtained on 2/29/23 of Resident #17 left knee due to continuing complaints of pain, the x-ray result was no acute injury. A phone interview with Nurse #4 on 3/3/23 at 1:22 PM revealed she just told the nurse aides about placing Resident #17 on a toileting schedule which was what she marked as a new intervention whenever she fell on [DATE] and on 2/28/23. Nurse #4 did not explain what a toileting schedule was to the staff or the times that the nursing assistants should take Resident # 17 to the restroom. An interview with Nurse Aide (NA) #4 was conducted on 3/2/23 at 1:15 PM. NA #4 stated that she was assigned to Resident #17 when she worked, and that Resident #17 was not on a toileting schedule and never had been that she was aware of. NA #4 further stated Resident #17 usually let staff know during the day if she needed to use the bathroom and NA #4 also asked Resident #17 before and after meals. Resident #17 was interviewed on 3/1/23 at 9:04 AM she stated that she was coming out of the bathroom and fell on [DATE]. She also stated that she hurt her hip and knee but that the nurse had given her pain medication. Resident #17 revealed she fell almost every day because she did not use the call light when she needed to use the bathroom. Resident #17 revealed that staff comes in her room when she does use the light but not at any other times that she can remember. An interview was completed with the Nurse Manager on 3/3/23 at 2:00 PM revealed she was responsible for updating the care plans and she usually looked at the reports and nursing notes daily. The Nurse Manager stated she did not update Resident #17's care plan after she fell on [DATE] and 2/28/23 with a toileting schedule. An interview was completed with the Director of Nursing (DON) on 3/3/23 at 2:51 PM. She stated that a toileting schedule should have been implemented for Resident #17. The DON further stated that each resident was different and that the toileting schedule should have been set up to meet Resident #17's needs to prevent further falls while trying to use the bathroom.

Based on observations, staff interviews, and record review, the facility failed to provide oxygen therapy per physician orders for 1 of 1 resident reviewed for respiratory care (Resident #12). The findings included: Resident #12 admitted to the facility on [DATE]. Resident #12 had diagnoses that included interstitial pulmonary disease, chronic respiratory failure with hypoxia and chronic systolic congestive heart failure. Review of the physician order dated 10/10/22 read in part: 3 liters oxygen (O2) via nasal cannula (NC) continuous. Resident #12's quarterly Minimum Data Set (MDS) dated [DATE] revealed severe cognitive impairment. Resident #12 was coded as receiving oxygen therapy. Review of Resident #12's care plan revised 01/24/23 revealed Resident #12 had oxygen therapy ordered and was at risk for onset of complications related to its use. The interventions included administer oxygen per Medical Doctor (MD) order. An observation was completed on 02/28/23 at 12:18 PM. Resident #12 was observed sitting up in bed eating independently with her NC in her nostrils. Resident #12's oxygen concentrator was observed at 2.5 liters. Resident #12 exhibited no signs or symptoms of distress. A follow up observation of Resident #12 was completed on 03/01/23 at 9:01 AM. Resident #12 was observed resting in bed with her NC in her nostrils. Her oxygen concentrator was observed at 2.5 liters. Resident #12 exhibited no signs or symptoms of distress. An additional observation was completed on 03/01/23 at 3:49 PM. Resident #12 was observed with her NC in her nostrils. The oxygen concentrator was set at 2.5 liters. Resident #12 exhibited no signs or symptoms of distress. An interview was completed on 03/01/23 at 4:34 PM with the first shift Nurse Aide (NA) #1. NA #1 stated Resident #12 was total care but could feed herself. NA #1 further revealed that NAs do not manipulate the oxygen setting on the concentrators. She continued to explain the NAs only turn the oxygen on or off after exchanging from room concentrator oxygen to portable oxygen if the resident were to leave the room. NA #1 stated, Resident #12's concentrator was always at 2.5 liters. NA #1 revealed she had not looked at the oxygen setting on 03/01/23, and usually only noticed the level when Resident #12 had to be switched from room concentrator oxygen to portable oxygen and back to room concentrator oxygen. An interview and observation were completed with Nurse #1 on 03/01/23 at 4:41 PM. Nurse #1 stated the Medication Administration Record (MAR) was checked off every shift, and that morning was the last time the oxygen setting was checked. Nurse #1 explained the oxygen setting was where the middle of the ball fell on a number line on the gauge of the oxygen concentrator. While in Resident #12's room, Nurse #1 communicated the ball was a little below three and it should be on three. Resident #12's oxygen saturation (amount of oxygen in the blood) was checked by Nurse #1 at 4:48 PM which read 98-99%. Nurse #1 was observed to adjust the oxygen concentrator setting to 3 liters. An interview was completed with the Director of Nursing (DON) on 03/01/23 at 4:50 PM. The DON stated NAs were familiar with the oxygen level for each resident because it was part of the resident's point of care (electronic Kardex system for NAs). The DON further revealed that the oxygen number line should be across the middle of the bubble. Nurses and NAs should check the rate of oxygen flow throughout the day. The DON continued to explain nurses should have checked the oxygen concentrator at least once per day to ensure correct oxygen settings as ordered by the MD as well as ensure the machine was working properly.

Based on observations and interviews with staff and the Pharmacy Consultant, the facility failed to remove an expired medication from 1 of 1 medication room and discard an uncapped eye medication in 1 of 2 medication carts (East Hall). The findings included: a. An observation of the medication room with Nurse #2 on 3/3/23 at 10:04 AM revealed a box of Epinephrine (medication used for emergency treatment of severe allergic reactions) marked with an expiration date of 12/2022. Two autoinjector 0.3 milligram syringes which were unopened and unused were inside the manufacturer's box. This box of Epinephrine was available for use in the medication storage cabinet in the medication room. An interview with Nurse #2 on 3/3/23 at 10:15 AM revealed that she had been unaware of the Epinephrine being expired and that the medication room was usually audited and checked by the Nurse Manager as well as the Pharmacy Consultant. An interview with the Nurse Manager on 3/3/23 at 2:00 PM revealed that she was responsible for ordering medications as well as checking the medication room. The Nurse Manager stated she did not know that there was expired Epinephrine in the medication storage room and that she had last checked the medication storage room about two weeks ago. A phone interview conducted with the Pharmacy Consultant on 3/3/23 at 2:15PM revealed that Epinephrine did not have an extended shelf life and that the expiration date on the box label was the expiration date and it should be discarded after that date. She stated that she did medication audits for the facility at least quarterly and that she completed the last audit on 12/5/22. An interview with the Director of Nursing (DON) on 3/3/23 at 2:45PM revealed that the medication storage room was audited frequently by the Nurse Manager as well as the Pharmacy Consultant. The DON stated that all expired medications should be removed promptly and reordered as necessary by the nurses and the Nurse Manager. b. An observation of the East hall medication cart with Nurse #2 on 3/3/23 at 10:30 AM revealed an uncapped Genteal eye gel (lubricant eye gel) in a small plastic bag for Resident #17. The uncapped end of the eye gel had pierced through the plastic bag and was exposed. An interview with Nurse #2 on 3/3/23 at 10:32 AM revealed that the ointment should have been discarded appropriately and another one should have been ordered from pharmacy. Nurse #2 also stated that the resident had an order to use the ointment in the evenings which was why she didn't notice it. An interview with the Nurse Manager on 3/3/23 at 2:00 PM revealed that if an uncapped eye gel had been found in a medication cart the nurse should discard the eye gel and reorder the medication from pharmacy. An interview with the DON on 3/3/23 at 2:15PM revealed that the nurses should not have kept the uncapped eye gel in the medication cart, and they should have discarded it if they couldn't find the cap and re-ordered another one from the pharmacy.

Based on record review and staff interview the facility failed to submit information for Preadmission Screening and resident review (PASRR) for a Level II evaluation for 1 of 1 resident reviewed for PASRR (Resident #20). The findings included: Resident #20 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. The MDS further coded the resident as having anxiety disorder, depression, and [MEDICAL CONDITION]. Review of Resident #20 PASRR screen Level I screen dated [DATE] identified Resident #20 no mental health diagnosis. Review of Resident #20 PASRR screen notification dated [DATE] revealed A PASRR number already existed and the existing PASRR number should be used until it expired. There was no expiration date identified on the PASRR notification. Review of physician order [REDACTED].#20 began the administration of [MEDICATION NAME] for use of [MEDICAL CONDITION] on [DATE]. Review of Resident #20 care plan revealed a problem start date of [DATE] for mood state. The problem further revealed Resident #20 expresses sadness/anger/empathy feelings over lost roles/status feeling of depression with [MEDICATION NAME] added as a mood stabilizer. The addition to the note stated [DATE] [MEDICATION NAME] was added for the [DIAGNOSES REDACTED].#20 would not exhibit sings of self-concept disturbance. The approaches included determine if mood endangers the resident and intervene if necessary and obtain a psych consult or psychosocial therapy. Review of Resident #20 psychiatric evaluation dated [DATE] revealed a chief complaint of depression, anxiety and irritable mood. The evaluation revealed the resident had multiple medical issues and anxiety, depression. Staff report no complaints of function, noting decreased in labile/irritable moods and recent distress related to traumatic history of sexual abuse as a child with nightmares and flashbacks. The note continued that the resident reported no nightmares with recent addition of [MEDICATION NAME] related to [MEDICAL CONDITION] episode. The note continued that the resident presented consistent with cluster B personality. Review of Resident #20 routine physicians visit dated [DATE] revealed Resident #20 had been stable for the past month. The note continued that Resident #20 began having increased signs of [MEDICAL CONDITION] and increased agitation. Resident #20 was started on [MEDICATION NAME] for [MEDICAL CONDITION], been on the medication for several months and was doing well. The assessment/plan stated [MEDICATION NAME] 2 milligrams (mg) by mouth at bedtime for [MEDICAL CONDITION]. Interview with the facility social worker on [DATE] at 9:48 AM revealed she was responsible for ensuring resident received a PASRR screening upon admission. She indicated that residents would typically come with a PASRR from the hospital they were being admitted from. She revealed she would submit PASRR screening for residents in the instance they went on hospice, had a significant decline or fracture. She indicated she was unaware if a North [NAME]ina Medicaid uniform screening tool (NCMUST) was required for a level II PASSR screen in the instance a resident obtained a new mental health disorder. Upon observation of Resident #20 PASRR dated [DATE] the social worker revealed the PASSAR screen did not match the resident as it did not identify the Residents [DIAGNOSES REDACTED]. Interview with the Administrator on [DATE] at 3:44PM revealed the social worker was responsible for resident PASRR. She further indicated in the instance the social worker or the MDS coordinator identified a resident had a new mental health [DIAGNOSES REDACTED].

Based on observation, record review and staff interview, the facility failed to apply Geri-Sleeves as care planned for 1 of 3 (Resident #9) reviewed for skin condition. Findings included: Resident #9 was admitted in the facility on 12/30/12 with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed the resident has a short term and long-term memory deficit. The resident was coded to have total dependence on bed mobility, transfer, and toilet use. She was also coded to have extensive assistance on dressing and personal hygiene with supervision for eating. Review of the Weekly Skin Assessment notes dated 12/16/19 revealed scattered bruising to extremities. The Care Plan dated 9/18/19 revealed Resident #9 had a skin tear to left wrist and left elbow and a Geri sleeves was added in the care to prevent from further skin tear. An observation on 12/16/19 at 10:28 AM, Resident #9 had a multiple bruise on her upper extremities and there were no Geri sleeves applied. Further observation on 12/17/19 at 1:07 PM showed no Geri sleeves were applied to her upper extremities. The Nursing Aide #4 (NA) was interviewed on 12/18/19 at 11:20 AM. NA #4 stated that the resident used to have a Geri sleeves about couple weeks ago and that it's not being used now. The NA showed me a copy of a written list of care needed for the resident and Geri sleeves were not included. She stated that all the care needed supposedly included in the list and she admitted that Geri sleeves were not written in the care list for Day of the Week print out. An interview with the MDS/Care Plan Coordinator on 12/18/19 at 11:01 AM, she stated that the care plan will show in the resident's Profile Care Plan Approaches. The Care Plan Approaches included all the care needed for the resident listed in the Day of the Week sheet. The MDS Coordinator showed the information in the computer and there were no Geri sleeves written in the profile. The MDS Coordinator further explained that the Geri sleeves were active, and it should show but she was not seeing it in the profile care plan approaches. Interview with the Director of Nursing (DON) was conducted on 12/19/19 at 10:47 AM. The DON stated she looked at the Day of the Week Sheet of the resident this morning and the Geri sleeves were included. The DON was shown a Day of the Week Sheet printed by NA#4 and from the Profile Approaches from the MDS coordinator that did not include the Geri sleeves, and the DON didn't give any reason why it was not showing a day prior. She stated that the Geri sleeves should be listed in the Day of the Week Sheet for the NA's to follow.

Based on observation, record review and staff interview, the facility failed to keep the catheter drainage bag lower than the bladder of 1 of 1 resident (Resident # 5) reviewed for catheter care. The findings included: Resident #5 was admitted in the facility on 4/25/16 with a [DIAGNOSES REDACTED]. The resident Minimum Data Set ((MDS) dated [DATE] revealed the resident with a Brief Interview for Mental Status (BIMS) score of 11 with moderate cognition impairment. An observation with Resident #5 on 12/16/19 at 11:44 AM shown the resident was up in the wheelchair in her room. It was observed that her catheter bag was concealed in a black bag hooked in the back of her wheelchair hooked across the push handle higher than her bladder. Other observations were done on 12/17/19 at 9:24 AM and 12:59 PM shown Resident #5 was in her wheelchair and her catheter drainage bag was in the back of her wheelchair. On 12/18/19 at 9:37 AM, Resident #5 was interviewed, and she stated that she kept her catheter drainage bag in a bag on the back of her wheelchair because her husband wanted it hidden. She also stated that nobody had told her to keep the catheter bag lower than her bladder and she further stated that if she had known, she would let the nursing staff position it lower or below her wheelchair. Resident #5 also claimed that she stays up from 6 AM up to 8 PM all the time. The Care Plan for Resident #5 last reviewed on 9/23/19 and indicated in the approaches to keep the catheter drainage bag below the level of the bladder at all times. An interview with the NA #3 was conducted on 12/17/19 at 2:11 PM. She stated that Resident #5 can communicate her needs well to the staff. She further stated that the resident had an indwelling Foley catheter with a drainage bag that is hooked in the back of the resident ' s wheelchair. NA #3 further stated that they placed the catheter in the back of the wheelchair to keep it hidden. Interview with Nurse #3 was done on 12/17/19 2:22 PM and she stated Resident #5 was very oriented and communicates her needs well. She stated that the resident was the one who liked her drainage bag in the back of her wheelchair. She further stated that she was educated with her catheter care. The Director of Nursing (DON) was interviewed on 12/19/19 at 10:40 AM. She stated that the proper way for catheter drainage bag should be lower than the resident ' s bladder.

Based on observation, policy review and staff interviews, the facility failed to label food including the use-by date and discard expired food from two of two reach-in refrigerators and two of four nourishment refrigerators. Findings included: The Date and Label Policy and Procedure dated 12/05/16 and signed by the Kitchen Manager included the following two excerpted statements: · Every food item had has been opened must be relabeled with an ' Opened on Date, ' ' Expires On Date, ' ' Employee Name, ' and ' Item. ' · All food items that have been prepped must be labeled with ' Opened on Date, ' ' Expires On Date, ' ' Employee Name, ' and ' Item. ' 1a. An observation of reach-in refrigerator #1 on 11/13/17 at 10:00 a.m. revealed the following expired items with hand-written labels: pesto with a preparation date of 11/06/17 to be used within five days, preserved limes dated 02/12/17 to be used by 05/12/17, Parmesan cheese wedges dated 10/04/17 to be used within 30 days, red wine glaze dated 08/24/17 with no use-by date, balsamic glaze dated 09/12/17 to be used within 30 days, a second container of balsamic glaze dated 05/31/17 to be used within 30 days, red salsa dated 09/28/17 to be used within five days, and roast beef dated 11/07/17 to be used within three days. Items were discarded by the Kitchen Manager. b. An observation of reach-in refrigerator #2 on 11/13/17 at 10:15 a.m. revealed the following expired items with hand-written labels: sugar-free pudding dated 11/07/17 to be used by 11/10/17, fruit cocktail dated 11/05/17 to be used by 11/10/17, fresh parsley dated 11/08/17 to be used by 11/09/17, and strawberries in a commercially labeled container with a handwritten date of 11/03/17 to be used by 11/11/17. An opened commercial container of cottage cheese was present with no labeling of date of opening or use-by date. Items were discarded by the Kitchen Manager. In an interview on 11/13/17 at 10:40 a.m., Dietary Aide #1 confirmed that she was one of two staff members assigned the task of removing expired items from the reach-in refrigerators. She stated her awareness of the food labeling policy. The aide indicated that she checked food items daily for expiration dates as she removed them for use. She did not set aside a specific time during the day to do a full inspection of each food in the refrigerators. In an interview on 11/15/17 at 12:15 p.m., the Kitchen Manager stated that dietary staff were trained upon hiring and as needed on dating and labeling of food items. The Date and Label Policy and Procedure 12/05/16 was posted in the kitchen. He indicated that the task of discarding expired items was assigned daily. He shared his expectation that pre-packaged foods were labeled with date of opening and expiration dates, and that expired prepared or commercial foods were removed from the refrigerator and discarded. 2a. An observation of the Dogwood unit nourishment room refrigerator on 11/16/17 at 11:45 a.m. revealed an unopened container of yogurt with no name or date and a vacuum-sealed package of coffee with no name or date. Also present was a plastic container labeled candy with pieces resembling fudge labeled with a resident name and date of 06/05. The use-by date was blank. In an interview on 11/16/17 at 11:50 a.m., Nurse #1 stated that food items should be labeled with name and date and should be used within three days or discarded. She removed the items from the refrigerator. b. An observation of the Rose unit nourishment room refrigerator on 11/16/17 at 12:00 p.m. revealed a vacuum-sealed package of coffee with no name or date. In an interview on 11/16/17 at 12:10 p.m., Nurse #2 acknowledged the unlabeled item and removed it from the refrigerator. She indicated that items need to be labeled with name, date received and use-by date. In an interview on 11/16/17 at 1:35 p.m., the Director of Nursing stated it was the responsibility of unit staff who use the refrigerators to ensure that foods brought in from outside the facility are properly labeled. She indicated the policy was posted in each nourishment room. She shared her expectation that foods were labeled with resident name and date and that items were discarded if the expiration date has passed.

Based on observations and staff interviews, the facility's Quality Assessment and Assurance (QA & A) Committee failed to prevent the recurrence of deficient practice related to the labeling and storage of food resulting in a repeat deficiency at F371. The citing of F371 during the previous federal survey showed the facility ' s inability to maintain an effective quality assurance (QA) program. Findings Included: This tag is cross referenced to F 371. Based on observation, policy review and staff interviews, the facility had failed to properly label food including the use-by date and discard expired food from two of two reach-in refrigerators and two of four nourishment refrigerators. A review of the facility ' s survey history revealed that F371 was cited during the facility ' s [DATE] annual recertification survey and then re-cited during the current [DATE] annual recertification survey. In the 2016 survey the facility had improperly stored boxes and cans of supplements in the walk-in refrigerator on the floor underneath thawing meat. In an interview on [DATE] at 2:30 p.m., the Administrator stated that the facility had a Quality Assurance and Performance Improvement (QAPI) program in place. He indicated that the QA & A Committee consisted of individuals in the following roles: Administrator, Director of Nursing, Minimum Data Set (MDS) Coordinator, Medical Director, Business Office Manager, Dietary Manager, Admissions Coordinator and all department heads. He shared his expectation that staff properly label food and promptly discard expired items. He further stated that the Dietary Manager and kitchen supervisors should monitor staff members daily to ensure these tasks are being done.

Based on observations, interviews with staff, and record reviews, the facility failed to safely provide a bed bath for 1 of 3 sample residents (Resident #2) reviewed for accidents. This occurred when the resident fell from her bed while one staff member was giving her a bed bath, resulting in the resident sustaining fractures of both her right and left femurs (the long bone of each leg). The findings included: Resident #2 was initially admitted to the facility on [DATE] from the community. A review of the resident ' s most recent annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 had intact cognitive skills for daily decision making. She was assessed to have moderate difficulty with hearing. No behaviors nor rejection of care were reported. The MDS assessment indicated Resident #2 required extensive assistance from two or more staff members for bed mobility and transfers. The resident required extensive assistance of one for locomotion on the unit, dressing, toileting, and personal hygiene; she was totally dependent on staff with assist of one for locomotion off the unit and for bathing. Resident #2 was independent with eating, but required assistance with meal set-up. Resident #2 had a functional limitation in the range of motion of her lower extremities (both sides). She utilized a wheelchair for mobility. Section J of the MDS assessment revealed the resident did not have any falls since her prior assessment. Section K reported Resident #2 was 60 inches tall and weighed 235 pounds (#). A review of the Care Area Assessment (CAA) Summary Reports for Activities of Daily Living (ADLs)/Rehabilitation Potential (dated 5/17/17) and Falls (dated 5/17/17) indicated the resident required staff assistance with ADLs (Activities of Daily Living) and mobility. She was non-ambulatory at the time of the review; staff assisted her with mobility on and off of the unit. No falls were noted. The CAA indicated a care plan would be developed for each of these care areas. The plan of care for Resident #2 included an area of focus related to ADL Functional/Rehabilitation Potential (initiated 3/22/17): The resident required assistance with ADLs and mobility related to Alzheimer ' s disease, [DIAGNOSES REDACTED], diabetes, convulsions, Vitamin D deficiency, anemia, and gastro-esophageal reflux disease. Approaches (interventions) listed for this area of focus were: --Explain procedure and why prior to attempt (Approach Start Date 3/22/17); --Monitor for presence of pain/intolerance during self-care. Provide pain medications as ordered. Monitor for effective response (Approach Start Date 3/22/17); --Provide adequate rest periods between activities (Approach Start Date 3/22/17); --Provide assistance for ADLs and mobility as needed (Approach Start Date 3/22/17); --Provide verbal cues and reminders for safety as needed (Approach Start Date 3/22/17); --Report any further deterioration in status to physician (Approach Start Date 3/22/17). Resident #2 ' s plan of care also included an area of focus related to Falls (initiated 3/22/17): The resident was at risk for falls due to weakness/impaired balance and decreased mobility related to chronic osteoarthritis pain in bilateral lower extremities. Resident was non-ambulatory. Resident also had dementia and received anti-seizure medications which may have further increased fall risk. Approaches (interventions) listed for this area of focus included: --Administer pain medications as ordered. Monitor for effective response and for side effects (Approach Start Date 3/22/17); --Assist with toileting and incontinence care as needed (Approach Start Date 3/22/17); --Increased staff supervision with intensity based on resident need. Place call bell and personal items within reach (Approach Start Date 3/22/17). A review of a Fall Huddle report dated 6/18/17 at 12:15 PM described an incident involving Resident #2 when she slid off the bed. The team summary noted, During her bath, (name of the Nursing Assistant or NA) had her laying over on her (left) side to wash her bottom. When done, she asked (name of Resident #2) to turn back over onto her back, but (name of Resident #2) turned further to the (left) and slid off the bed onto her knees. The Action Plan read, Speak loudly into (name of Resident #2) ear when speaking to her due to her being HOH (hard of hearing). A review of the resident ' s medical record included a Nursing Note dated 6/18/17 at 4:32 PM. The note reported: Resident slid off her bed onto her knees during her bath. She was gotten up using the (brand name) lift (a mechanical lift). She sustained a skin tear on her R (right) forearm and c/o (complained of) both knees hurting. No bruising/swelling noted. Resident ' s (family member) made aware, nursing supervisor made aware and (name of on-call physician) ordered an x-ray of both knees and to observe her. Further review of the resident ' s medical record included an x-ray report dated 6/18/17 at 6:31 PM. The report included an impression of the left knee indicating there was an acute distal femur fracture. The report also noted x-rays indicated the resident had a possible non-displaced fracture involving the distal right femur. A Nursing Note dated 6/19/17 at 3:22 AM indicated the x-ray reports of the resident ' s left and right knees were faxed to the resident ' s physician. Another Nursing Note dated 6/19/17 at 12:34 PM revealed the facility ' s Nurse Practitioner (NP) instructed the facility to send the resident out to the Emergency Department. The resident left the facility via an Emergency Medical Service at 12:15 PM. A review of the hospital records included x-ray reports dated 6/19/17. The reports indicated Resident #2 had a mildly displaced metaphyseal fracture (also known as a corner fracture) of her distal right femur (the end of the long bone of the right leg down by the knee). She also had a displaced mild impacted minimal comminuted fracture (indicating the bone was broken into pieces) of the distal left femoral metaphysis (the end of the long bone of the left leg down by the knee). Further review of Resident #2 ' s hospital records included the Emergency Department Provider Notes. The notes indicated Resident #2 was evaluated in the Emergency Department. She was placed in splints and it was determined non-operative management was appropriate since the resident was already non-weight bearing and non-ambulatory. Her family was reported as comfortable with the plan for pain management. Resident #2 returned to the facility on [DATE] at 10:30 PM. A review of the resident ' s medical record included a Nursing Note dated 6/23/17 at 3:46 AM. The notation revealed Resident #2 was resting on a new Bariatric bed with an air mattress. A review of the resident ' s medical record also revealed a Hospice referral was made on 6/24/17. Resident #2 was admitted to Hospice Care on 6/27/17 with a [DIAGNOSES REDACTED]. A Fall Risk Assessment was completed for Resident #2 on 6/29/17. Her total Fall Risk score was = 17.0, indicating the resident was at risk for falls. A notation was made on the fall risk assessment to continue the current plan of care. On 6/30/17, an MDS assessment was completed due to a significant change noted for Resident #2. This assessment revealed the resident was assessed by staff as having modified independence in regards to her cognitive skills for daily decision-making. No behaviors nor rejection of care were reported. The MDS assessment indicated Resident #2 required extensive assistance from two or more staff members for bed mobility, dressing, toileting, and personal hygiene. She was totally dependent on staff for transfers and locomotion on/off the unit with assistance of one, and bathing with assistance of two or more staff members. The resident required supervision with eating and the assistance of one staff member. The MDS indicated Resident #2 had a functional limitation in the range of motion of her lower extremities (both sides) and she utilized a wheelchair for mobility. Section J of the MDS assessment revealed the resident had one fall with a major injury since her prior assessment. The resident ' s assessment revealed she had a condition that may result in a life expectancy of less than 6 months. The MDS also indicated Resident #2 was receiving Hospice care. A review of the resident ' s Care Area Assessment (CAA) Summary Reports for ADLs / Rehabilitation Potential (dated 7/6/17) reported the following, in part: Resident requires increased staff assistance with ADLs due to recent fall from her bed during bathing task .She has bilateral leg splints in place. (Brand name) catheter inserted prior to this review due to prolonged immobility and comfort. Resident requires incontinence care and hygiene by staff due to stool incontinence. A review of the resident ' s Care Area Assessment (CAA) Summary Reports for Falls (dated 7/6/17) also reported the Resident requires increased staff assistance with ADL ' s due to recent fall from her bed during bathing task with staff. No other recent falls noted. Resident #2 ' s care plan for ADL Functional / Rehabilitation Potential was revised on 9/26/17 to include, Update: bilateral femur fractures s/p (status [REDACTED]. Resident #2 ' s care plan interventions related to Falls were updated on 6/27/17 and 9/26/17 to include the following: --Place bed in low position when care is complete (Approach Start Date 9/26/17); --Reposition as needed with 2 assist for comfort (Approach Start Date 9/26/17); --Bed mobility/turning assist of 2 staff (Approach Start Date 6/27/17). Resident #2 ' s care plan also included an area of focus related to Hospice (Problem Start Date 6/29/17): Resident is on Hospice Care related to end of life care. A review of the resident ' s medical record included a Nursing Note dated 9/26/17 at 11:04 AM which read, in part: .Bedfast d/t (due to) femur fractures .Staff unable to get weight on resident since femur fracture injuries in 6/2017, but visibly has lost weight (face thin, sunken in). Res. (Resident) Noted with significant decline last few months. Remains on hospice care d/t condition. Will continue to monitor. An observation was conducted on 9/26/17 at 12:20 PM of Resident #2 as she was lying in bed asleep. The resident ' s bed was identified as a bariatric bed with an air mattress in place. She appeared to be resting comfortably. An interview was conducted on 9/27/17 at 11:43 AM with the facility ' s Assistant Director of Nursing (ADON). Upon inquiry regarding Resident #2 ' s fall on 6/18/17, the ADON reported one NA who had bathed the resident many times before gave the resident a bed bath. The NA raised the bed for the bed bath. While giving Resident #2 her bed bath, the NA turned the resident over onto her side and positioned the resident ' s leg over her without realizing how close she was to the edge of the bed. When the NA instructed the resident to roll back, the resident rolled forward instead. The ADON noted Resident #2 was hard of hearing. She reported there was an investigation from Risk Management in regards to this fall and safety interventions were put into place. The ADON reported the resident ' s bed was replaced with a bariatric bed. She explained the regular-sized bed was not appropriate for the resident because of her wide girth. The ADON also stated the facility put into place a 2-person assist for the provision of Resident #2 ' s care. The facility did a house-wide sweep and replaced two more residents ' beds with bariatric beds. Additionally, the staff was educated on communicating with and taking care of residents who were hard of hearing. The ADON reported fall audits (consisting of the numbers and injuries) has been a part of the facility ' s usual Quality Assessment and Assurance (QAA) process. Accompanied by the ADON, an observation was made on 9/27/17 at 11:50 AM of Resident #2 as she was lying in her bed with a visitor by her side. A bariatric bed was observed to be used for the resident with an air mattress in place. The resident was sleeping soundly; she appeared to be resting comfortably. An interview was conducted on 9/27/17 at 12:07 PM with the facility ' s Administrator. During the interview, the Administrator was asked if a Quality Assessment and Assurance (QAA) plan had been developed to monitor any new systems put into place to ensure residents ' safety during the provision of ADL care. The Administrator indicated the issue of falls was already a component of the QAA meetings where the number of falls were discussed. However, the Administrator reported he was new to the position (started June 2017) and had only been involved in one QAA meeting to date. A follow-up interview was conducted on 9/27/17 at 1:30 PM with the ADON. The ADON provided a copy of the written in-service education given to the nursing staff (dated 7/11/17). She explained the written information was put in a Communication Book kept at each of the five nursing stations. Nursing staff were asked to sign an Education Attendance Record upon review of the written information. When asked if all nursing staff had received the education, the ADON stated she was not sure. A review of the in-service education dated 7/11/17 revealed training consisted of two main topics: (1) Obese Resident: Charge Nurse and Nurse Techs our current beds can hold a certain amount of weight, however, we have found that depending on how our resident ' s weight is distributed, our beds have been found to not be safe. So going forward: *Charge Nurses when getting report for your new admission, obtain HT (height) and Weight. This will give us a chance to review proper bed side. If you have concerns notify (name and phone number of ADON). *Review the fit/size of all current resident to ensure proper bed size beds. We need to ensure that the resident can be safely turned and ADL ' s performed when in bed. Do we need a bariatric bed? Notify (name and phone number of ADON) ASAP (as soon as possible) if you have any concerns about a resident ' s bed size and/or safety. *We encourage the use of 2 staff members when caring for the obese resident. This for the resident ' s safety as well as yours. (2) When Caring for the Hard of Hearing Resident: 1. Realize that you don ' t have to SHOUT! Shouting actually makes communication harder to understand. It can also be somewhat intimidating, and embarrassing. 2. Deliver your message face-to-face, rather than from across the room or from the next room. We all use lip-reading to some extent to help us hear. 3. Eliminate background noise, Turn off the TV or radio. Even the low hum of the dishwasher or a leaf blower outside can muffle your words. 4. Don ' t rely on hearing aids working perfectly. If you find that someone with a hearing aid is having trouble hearing well or isn ' t using it, ask questions to find out why. Is it uncomfortable? Is ambient sound interfering? 5. Especially with someone who has dementia, avoid talking while coming up from behind him or her. You may not be heard until you ' re right upon the person, causing your loved one to be started and flustered-and not comprehend a word you ' ve said. 6. If the person has vision problems, know what his or (her) range of vision is. For some people, there ' s little peripheral vision (on the sides), so you must be positioned squarely in front to be seen and understood. This information can be obtain from eye MD (Medical Doctor). 7. Speak slowly and clearly. You don ' t have to dumb down your speech to robot tones, but try not to rush through your sentences, either. You ' ll be more easily heard by any listener, of any age or health condition. An interview was conducted on 9/27/17 at 1:50 PM with NA #1. NA #1 was identified as the nursing assistant who gave Resident #2 her bed bath at the time of her fall on 6/18/17. During the interview, the NA reported she did not normally take care of Resident #2, but had cared for her in the past. The NA stated when she was giving the resident a bed bath, she assisted her to roll over so the resident ' s back was facing her. After NA #1 had washed the resident, the NA asked the resident to roll back towards her. However, Resident #2 rolled forward and the NA stated she could not catch her. NA #1 stated the hall nurse was in the room working with Resident #2 ' s roommate at the time of the fall. NA #1 stated she did not feel comfortable moving the resident, but the nurse decided to use the Hoyer lift to get her up in her chair. After putting her in the chair, they decided to transfer the resident to her bed because she was in pain. NA #1 reported the fall was investigated by the facility and a larger bed was obtained for Resident #2. NA #1 stated she herself no longer worked on Resident #2 ' s hall, but understood staff members were instructed to use a 2-person assist for all of the care provided to this resident. When asked how many residents on her current hall assignment needed to have 2-person assistance, she responded, at least two (residents). Upon inquiry as to whether 2-person assistance was utilized when providing care to these residents, the NA stated, Not always. A telephone interview was conducted on 9/27/17 at 2:30 PM with Nurse #1. Nurse #1 was identified as the nurse who was assigned to Resident #2 ' s hall on 6/18/17 at the time of her fall. During the interview, Nurse #1 stated she was in Resident #2 ' s room attending to her roommate at the time of the fall. The nurse reported she knew the nursing assistant (NA) was giving Resident #2 a bed bath and the privacy curtain. The nurse reported hearing NA #1 tell the resident, Okay, come on back over. Nurse #1 recalled a few seconds later she heard the resident scream out in a hurtful voice. When the nurse got to Resident #2 ' s side of the room, she saw the resident was on her knees on the floor (on the opposite side of the bed from the NA). NA #1 told the nurse that when she told Resident #2 to come back over, she rolled the other way. At that point, Nurse #1 and NA #1 used a mechanical lift that was already in the room and put her on the bed. The nurse reported the resident was crying and saying her legs hurt so bad. Nurse #1 stated she did an assessment and checked the resident ' s range of motion. She then called the resident ' s physician, who told her to monitor the resident. After a couple of hours, the nurse stated she called the physician back and got an x-ray ordered. When the nurse left her shift that day, the mobile x-ray report had not yet come back. Upon inquiry, Nurse #1 reported she has worked one time on the resident ' s hallway since her fall. The nurse stated she has not received in-service training related to safety issues for residents since the incident occurred. Nurse #1 reported that she herself made the suggestion that if a resident required a Hoyer lift for transfers, he/she should have two nursing assistants for all incontinence care, bathing, and transfers. When asked if two-person assistance was always provided for residents identified as requiring it, the nurse replied, No. An unsuccessful attempt was made to contact Nurse #2 for a telephone interview on 9/27/17 at 4:05 PM. Nurse #2 was typically assigned to work on Resident #2 ' s hall. A voice mail message was left requesting a return phone call. An interview was conducted on 9/27/17 at 4:15 PM with the facility ' s Director of Nursing (DON). Upon a review of the nursing staff employment list compared to the 7/11/17 Education Attendance Records, the DON confirmed not all staff received the in-service education. A review of a list of the facility ' s nursing staff (licensed and unlicensed) indicated there were 84 nursing staff members (54 NAs and 30 nurses) who worked at the facility. The in-service Education Attendance Record (dated 7/11/17) with the subjects of Obese Resident and When Caring for the Hard of Hearing Resident included the signatures of 21 nursing staff members (12 NAs and 9 nurses) on three separate signature sheets. The DON noted the Administrative staff was unable to locate the signature sheets from two of the five nursing stations. A follow-up interview was conducted on 9/27/17 at 4:30 PM with the DON. Upon inquiry, the DON confirmed Resident #2 did not have an assessment (including a Fall Assessment) prior to her annual MDS to determine the number of staff required for the safe provision of ADL care. The DON also noted this MDS assessment (dated 5/5/17) indicated the resident required extensive assistance from two or more staff members for bed mobility. The resident was totally dependent on staff with the assistance of one for bathing. An interview was conducted on 9/27/17 at 4:32 PM with the facility ' s MDS nurse. During the interview, the nurse reported a former MDS nurse (no longer employed by the facility) completed Resident #2 ' s annual MDS assessment dated [DATE]. The current MDS nurse reported the electronic Point of Care ADL Report was likely used to determine the coding of Section G (ADLs) on the MDS. A review of the ADL report from the facility ' s electronic record revealed the MDS had been coded correctly to reflect the ADL assistance provided to the resident for the 7- day look back period (4/29/17-5/5/17). An interview was conducted on 9/27/17 at 2:53 PM with NA #2. During the interview, the NA reported she was very familiar with the residents on the hall, including Resident #2. NA #2 reported Resident #2 was supposed to have the assistance of two staff members for all of her ADL care. When asked if 2-person assistance was always provided for those residents who required it, the NA indicated it was not. The NA reported that sometimes (particularly on weekends) there may be only one NA assigned to a hall, making it very difficult to provide 2-person assistance for residents who required it. An interview was conducted on 9/27/17 at 5:30 PM with the DON. The Administrator joined the interview on 9/27/17 at 5:35 PM. During the interview, the DON noted was new in her position at the facility and was not on staff when Resident #2 fell (6/18/17). The DON was asked what her expectations would have been in regards to the resident ' s ADL care as it related to the fall on 6/18/17. The DON stated that for the resident ' s care at the time, she thought one NA providing her bath was adequate as there had been nothing like in her history to suspect that (the fall) would have happened. The DON also reported she would have liked to have seen documentation of the in-service education for all 5 nursing stations, along with documentation of monitoring for the interventions implemented after the resident ' s fall. Multiple attempts were made to interview the resident. However, the resident was very sleepy and unable to be interviewed. On 9/28/17 at 10:27 AM, Nurse #2 returned the telephone call placed to her on 9/27/17 and a telephone interview was conducted. Nurse #2 reported she was not assigned to Resident #2 ' s hall at the time of her fall. However, she stated she was very familiar with the resident (both before and after her fall in June, 2017). During the interview, the nurse was asked what interventions had been put into place to safely provide ADL care for Resident #2 since her fall. Nurse #2 reported the facility reassigned the NA who provided the resident ' s bed bath when she fell to a different hall. Nurse #2 stated, All of the staff concurs that (the fall) could have been prevented. The nurse explained further by stating there should have been a second nursing assistant helping NA #1 to give the resident a bed bath. She reported any movement of the resident (even before her fall) should have required two staff members. The nurse added, This is something that should not have happened. When asked how the facility ' s NAs would know how much assistance a resident needed for ADL care (1-person assistance versus 2-person assistance), the nurse stated, They don ' t know. She reported this type of information was verbally shared from one nursing staff member to another. The nurse added, You and I both know that ' s not the best way.

Based on record review and staff interviews, the facility failed to develop a policy and procedure that included the process of educating residents and/or families of the benefits and potential side effects of the influenza and pneumonia immunizations for 3 of 5 residents (Resident #193, Resident #63 and Resident #176) reviewed for immunizations. The findings included: The facility ' s policy dated 10/2015 and titled Immunizations and Documentations was reviewed. There was no documentation in the policy that reflected how the facility would provide education to residents and/or families (both upon admission and annually). 1a. A review of the facility ' s Preventive Health Care report dated 1/1/01-12/8/16 revealed that Resident #193 received the pneumonia vaccine on 8/10/16 but that education material was not provided. 1b. A review of the facility ' s Preventive Health Care report dated 1/1/01-12/8/16 revealed that Resident #63 received the influenza vaccine on 9/12/16 but that education material was not provided. 1c. A review of the facility ' s Preventive Health Care report dated 1/1/01-12/8/16 revealed that Resident #176 received the influenza vaccine on 9/27/16 but that education material was not provided. An interview with the Director of Nursing (DON) on 12/8/16 at 12:12pm confirmed that the policy did not include the education component. The DON reported that the education information is provided in the Admissions packet, along with an acknowledgement form that the resident or family signs, however, the policy did not reflect that information. During an interview with the DON on 12/8/16 at 2:10pm it was reported that when the state was here last year this was an issue and we thought we had fixed it but we haven ' t. She confirmed that annual education for vaccines is not addressed.

Based on record review and staff interview, the facility failed to complete a comprehensive assessment (Minimum Data Set and Care Area Assessment) within 14 days after admission to the facility for 1 of 16 sampled residents (Resident # 160) reviewed for comprehensive assessments. The findings included: Resident #160 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) 6/12/16 and Care Area Assessment (CAA) revealed that the CAA for Cognition was completed by Social Worker #2 on 7/6/16 at 09:25am, 31 days after admission and the CAA ' s for Activities of Daily Living and Falls were completed by MDS Nurse #1 on 7/5/16 at 4:14pm and 4:17pm, respectively, 32 days after admission. During an interview with the MDS Nurse #1 on 12/08/16 at 10:37am, it was confirmed that the CAAs are due 14 days after admission and they are always late. The MDS Nurse #1 confirmed that the CAAs were initiated but not completed until the dates listed above. During an interview with the Director of Nursing (DON) on 12/08/2016 at 9:54am it was communicated the expectation was that the staff follow all policies and complete documentation on time. The DON further stated that it is her expectation that residents are correctly assessed and coded. An interview with the Administrator on 12/08/2016 at 2:32PM revealed that it was his expectation that the comprehensive MDS assessments would be completed as required and staff notify administration when assessments are not completed in a timely manner.

Based on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 92 days of the previous quarterly MDS assessment for 1 of 16 residents (resident #152) reviewed. The findings included: A review of resident #152 admission MDS was dated 5/13/16. The assessment revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident ' s MDS assessment dated [DATE] was marked as quarterly assessment and was signed as being completed on 8/29/16. During a review of the resident ' s most recent quarterly MDS assessment dated [DATE] revealed the assessment was in progress and not completed. Further review of the assessment revealed Section Z for signature of persons completing the assessment and Registered Nurse assessment coordinator verifying assessment as complete was noted to be blank and no date entry noted. During an interview with MDS Coordinator #1 on 12/07/2016 at 08:04 AM, the MDS Coordinator stated that she is aware that the quarterly assessment is incomplete for Resident # 152. The MDS Coordinator further stated that she is behind on her assessments. During an interview on 12/08/2016 at 9:54 AM with the facility ' s Director of nursing (DON), she stated that it was her expectation that all assessments be completed on time. During an interview with the Administrator on 12/08/2016 at 2:32PM, the Administrator stated it was his expectation that the all MDS assessments would be completed as required and staff notify administration when assessments are not completed in a timely manner.

Based on observation, record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident that had palliative care and the nursing home staff providing care, and bowel appliances for 2 of 16 sampled residents (Resident # 63 and 152). The findings included: 1. Resident # 63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] marked as a significant change assessment, revealed the assessment was coded as the resident ' s activity of daily living (ADL) as follows: bed mobility as activity occurred only once or twice with one person physical assistance for 7 of 7 days of the assessment period. The resident ' s transfers, dressing, toileting, personal hygiene, bathing and eating was coded as the activities did not occur at any time for 7 of the 7 days of the assessment period. The assessment also had marked that the resident did not have a life expectancy of less than 6 months. Review of the initial hospice assessment dated [DATE] indicated that the resident had a prognosis of 6 months or less. Review of a physician note dated 10/ 25/16, had documentation of palliative care consult related to declining health. Another Physician note dated 10/27/16 revealed hospice referral had been ordered. Review of the resident ' s most recent updated care plan dated 10/31/16 revealed hospice care started on 11/1/16 with a goal to keep resident comfortable and interventions to provide basic comfort measures like oral care, hygiene, position changes, etc. to be provided by both hospice and facility nursing. During a review of the hospice nursing assistant progress notes dated 11/16/16, revealed the resident was provided a bath and all care. Resident was checked throughout the day and toileted as needed. Meal intake was documented as breakfast 90% and lunch 100%. Review of hospice nursing notes dated 12/2/16 revealed the resident was provided care in accordance to hospice care plan and the resident consumed 75% of breakfast. During review of the facility nursing notes dated 11/27/16 the resident was provided a bath and was dressed with the assistance of one person. The Nursing home nursing staff note further indicated that the resident was fed by nursing home staff. Review of the facility nursing notes from the weekend of dated 12/3/16 read in part: resident assisted with activities of daily living (ADL ' s) from the nursing home staff. Review of the facility ' s dietitian notes dated 11/11/16 revealed resident ' s diet was reviewed by the facility ' s dietitian to provide more variety, comfort care and honor family and resident wishes. Review of dietitian notes dated 11/27/16 revealed resident was currently on a regular diet and Gatorade was included on both the lunch and supper tray. An observation of resident #63 made on 12/06/2016 at 1:38 PM revealed Resident #63 sleeping in a geriatric chair in her room. Nursing home staff walked into resident ' s room to see if resident was comfortable. An observation was made on 12/07/2016 at 8:44 AM of Resident #63 being fed by hospice staff. Resident was sitting on a geriatric chair and watching television. An observation was made on 12/07/2016 at 2:35 PM of Resident #63 sleeping on her bed. An interview with the nurse #1 on 12/07/2016 at 7:32 AM, the nurse stated that the resident is provided care in the morning by hospice staff and facility ' s nursing assistants and nursing staff provide resident ' s care during the night and over the weekend During an interview with the nurse #7, on 12/07/16 at 8:41 AM, the nurse stated that the resident ' s activity of daily living were taken care during the day by the hospice nursing assistant Monday through Friday . The nurse further stated that the resident ' s needs are taken care by facility staff during nights shift and over the weekend During an interview with the hospice Nursing Assistant #1 on 12/07/2016 at 8:45 AM, she stated that the resident is total care. She further stated that the resident ' s toileting needs are addressed as needed. She stated that resident was usually fed breakfast and lunch and the meal intake was documented in the chart. During an Interview with the MDS Nurse #1 on 12/07/2016 at 10:30 AM, the MDS coordinator stated that resident was on hospice care and a change of status MDS assessment was completed on 11/30/16. She further stated that resident ' s functional status like bathing, transfer, walking, toileting, dressing and personal hygiene are marked as activities never occurred on the MDS because care is provided by non-staff members. She stated that the resident ' s family, hospice care staff or nursing students take care of resident ' s activity of daily living. She further stated that according to the regulation, if the resident is not assisted by facility staff then it should be coded as Activity did not occur - family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period . Additionally, the MDS nurse stated that it was an oversight on her part for not marking the prognosis as terminally ill. During an interview with Director of Nursing (DON) on 12/07/2016 at 11:52 AM, the DON stated that the resident is provided care both by hospice and facility staff. She further stated that the resident does not receive 24 hours hospice service, but receives care by the facility staff in the night and over the weekend. She also stated that her expectations are for staff to follow the correct procedure when MDS assessments are completed. The DON further stated that the functional status section on MDS was incorrect. 2. A review of resident #152 admission MDS was dated 5/13/16. The assessment revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive MDS dated [DATE] coded as admission MDS revealed the facility coded resident for activities of daily living- eating as activity never occurred and nutrition approach was marked as [MEDICATION NAME] IV feedings. Review of bladder and bowel appliance was not marked for ostomy. Review of the nursing admission progress note dated 5/6/16 read in part: Patient is nothing by mouth (NPO) and Total [MEDICATION NAME] Nutrition (TPN) is administered through peripherally inserted central catheter (PICC) line for 16 hours. Patient fistula bag ordered to be changed every (q) 3 days. Review of the quarterly MDS dated [DATE] revealed ostomy bag not marked for bladder and bowel appliance. Review of quarterly assessment dated [DATE] revealed the facility coded the resident ' s activities of daily living as: transfers, walking, eating, and toileting did not occur any time during the 7 day look back period. The resident ' s bed mobility, dressing and personal hygiene was coded as having only occurred once or twice during 7 day look back period. Review of bladder and bowel appliance was marked for ostomy. During an interview with nurse #7 on 12/08/2016 at 9:15 AM, the nurse stated that the resident was admitted with a [MEDICAL CONDITION] bag. The nurse further stated that the resident has had his nutrition provided via Total Parental Nutrition. During an interview with MDS nurse #1 on 12/08/2016 at 10:00 AM, she stated that she had not realized that there was a data error in the admission MDS. She further stated that she had made an error regarding how she coded the resident ' s activities of daily living. During an interview with Director of Nursing (DON) on 12/08/2016 at 9:54 AM, DON stated that she is well aware about the resident having an ostomy bag and that he was admitted on [MEDICATION NAME] Nutrition. The DON further stated that the resident should have been coded for having an ostomy bag. The DON stated that it is her expectation that residents are assessed and coded on the MDS correctly. During an interview with the facility administrator on 12/08/2016 at 2:32 PM, the administrator stated it is his expectation that the staff assess the residents appropriately and fix any the errors as soon as identified.

Based on record reviews and staff interviews the facility failed to develop a care plan for implementing measures for 1 of 3 residents (Resident #232) who received an antianxiety medications and for behaviors of yelling out, for 1 of 3 residents (Resident #152) for ostomy care related to a bowel appliance (ostomy), and for 1 of 3 residents (Resident #206) for incontinent care. The findings included: 1. Resident #232 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The MDS further indicated Resident #232 was severely cognitively impaired as evidenced by a Brief Interview for mental status (BIMS) of 3. Review of Resident #232 ' s care plan dated 10/20/16 revealed a problem of I receive antidepressant medication and I am at risk for adverse effects. The goal stated Resident #232 would not experience adverse effects of medication through next review. The approaches included administer medications per medical doctor (MD) order, assess/record effectiveness of drug treatment, monitor and report signs of sedation, [MEDICAL CONDITION], or [MEDICATION NAME] symptoms, drug reduction as recommended by pharmacist and pharmacy consult review. Review of Resident #232 ' s care plan revealed no care plan for the administration of an antianxiety medication. The care plan further revealed no care plan in regards to Resident 3232's behaviors associated with the use of an antidepressant medication nor an antianxiety medication. Review of Resident #232 nursing note dated 11/12/16 revealed, Resident #232 had been yelling continuously for help today. Could not pinpoint what he wanted help with just that he needed help. Family member present and Resident #232 continued while she was sitting beside him. Review of initial psych note dated 11/14/16 revealed a chief complaint of stabilization of anxious behavior. Staff reported Resident #232 yelled out, had disorganized behavior and was perseverated over his bowels. Resident #232 complained of having loose stools, impaction, and bowel movements. The not continued that staff had checked him numerous times. Resident #232 thought he had bed sores on his backside. He has even described the bedsores to staff. The family stated these behaviors are new since Resident #232's [MEDICAL CONDITION]. Resident #232 seemed to be fixated on his bowels. Tends to be more anxious when family member not there. Recommend were to start [MEDICATION NAME] 30 milligrams (mg) by mouth (po) qd (once a day) x 5 then increase to 60mg po qd thereafter for depression. The [DIAGNOSES REDACTED]. Review of Resident #232's nursing note dated 11/17/16 revealed Resident #232 had been yelling all shift help me and he constantly stated he has a had a bowl movement. Resident #232 was checked and he was full of soft stool. Resident #232 was assisted out of bed by sit to stand lift to sit on the toilet in which he an extra-large bowl movement. Resident #232 continued to yell while in the bathroom to get off the toilet. The note continued with when Resident #232 was stood up and had another large bowel movement. Resident #232 yelled though lunch time help me refusing to keep his oxygen on. The NP was notified of the continued behaviors and new orders received to administer [MEDICATION NAME]. Review of Resident #232's physician order [REDACTED]. Review of Resident #232's physician order [REDACTED]. Review of Resident #232's physician order [REDACTED]. Review of Resident 3232 ' s nursing note dated 11/27/16 revealed Resident #232 was yelling out saying he had diarrhea but when checked there was no stool noted. Review of psych follow up note dated 12/1/16 revealed Resident #232 was seen for a chief complaint of stabilization of anxious behaviors. The history of present illness indicated Resident #232 was previously seen for yelling out, disorganized thinking and perseverating over his bowels. Staff reported Resident #232 was doing much better. He was less anxious, perseverative. The note continued with Resident #232 had no tolerability issues with [MEDICATION NAME]. Medications were identified as [MEDICATION NAME] 60mg for depression and [MEDICATION NAME] 0.5mg every 4 hours PRN for anxiety. Interview with NA#6 on 12/7/16 at 11:30am revealed Resident #232 exhibited behaviors such as yelling out when he had taken a BM or his bottom was burning. She indicated that checking the resident, cleaning him following a bowel movement, or putting cream on his bottom would minimize the behaviors. Interview with Nurse #6 on 12/8/16 at 7: 44 am reveled resident #232 behaviors consisted of yelling out constantly. The resident normally yelled out in the instance he believed he had a bowl movement. Nurse #6 stated one day resident #232 was really anxious so we got an order for [REDACTED]. Interview with MDS Coordinator #1 on 12/8/16 at 11:05am indicated a care plan for anxiety should have been developed. She revealed she became aware of medication changes and behaviors in morning stand up meetings. MDS Coordinator #1 indicated she had missed including the use of an antianxiety medication to Resident #232 care plan. She indicated she care planned behaviors in the instance a resident had [MEDICAL CONDITION] or combative behaviors. Resident #232 behaviors were far and few in-between. Interview with the Director of Nursing (DON) on 12/8/16 at 2:50 pm revealed it was her expectation that the Resident care plans were developed and revised to reflect the resident ' s current plan of care. The DON further revealed the MDS coordinator received changes in medications and the care plan should reflect the changes in the resident's medications. 2. A review of resident #152 admission MDS was dated 5/13/16. The assessment revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility coded resident as having [MEDICATION NAME] IV feedings for nutrition approach. Review of bladder and bowel appliance was not marked for ostomy. Review of the nursing admission progress note dated 5/6/16 read in part: Patient is nothing by mouth (NPO) and Total [MEDICATION NAME] Nutrition (TPN) is administered through peripherally inserted central catheter (PICC) line for 16 hours. Patient fistula bag ordered to be changed every (q) 3 days Review of quarterly assessment dated [DATE] revealed the facility coded resident as having an ostomy bag. A review of the resident #152 active care plan was originally dated 5/19/16 and last revised on 11/30/16 revealed no documentation or care plan in place for resident ' s ostomy care. During an interview with nurse #7 on 12/08/16 at 9:15 AM, the nurse stated that the resident was admitted with a [MEDICAL CONDITION] bag. During an interview with MDS coordinator on 12/08/16 at 10:00 AM. She stated that she had not realized that there was a data error in the admission MDS. She further stated that she was not aware that the resident was not care planned for ostomy care, but she indicated a care plan should have been developed for ostomy care. During an interview with Director of Nursing on 12/08/16 at 9:54 AM, DON stated that she is well aware about the resident having an ostomy bag. DON further stated that the resident should have been coded for ostomy bag. She also stated that the resident should have a care plan of ostomy care. The DON stated that it is her expectation that residents are assessed and care planned accurately. During an interview with the facility administrator on 12/08/16 at 2:32 PM, the administrator stated it is his expectation that the staff assess the residents appropriately so that the Care Area Assessments (CAA) are triggered and physicians have orders to address all the required CAA triggered care areas. 3. Resident #206 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Coli, fracture of right femur, history of falling and abnormalities of gait and mobility. frequent incontinence Review of admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #206 to have (defined as 7 or more episodes of urinary incontinence but at least one episode of continent voiding). Care Area Assessment (CAA) Summary triggered urinary incontinence and care plan decision. Review of Resident #206's medical record revealed no care plan or interventions for Resident #206 incontinence. Care plans (CP) dated 08/26/26, 09/13/16 and 09/28/16 did not indicate urinary incontinence as a problem on care plan. Last care plan conference noted on CP was dated 09/15/16. Review of 90-Day MDS assessment dated [DATE] revealed significant change in Resident #206 status compared to the Admission MDS. MDS revealed that resident is always incontinent. Interview with MDS nurse #1 on 12/6/16 at 2:4pm revealed bladder and/or bowel episodes that were coded as frequent incontinence or always incontinent were always care planned. MDS Nurse #1 reported that a care plan should have been developed for Resident #206 urinary incontinence but was not. Interview with the DON on 12/06/16 at 2:34pm revealed it was her expectation that any concerns, problems or new situations should be addressed in the care plan in a maximum of 2 days. The DON stated that the interdisciplinary team meet Monday-Friday to discuss each resident's status. DON indicated that if a change in a resident is communicated, the CP is usually updated by MDS Nurse #1 or MDS Nurse #2 at that time. The DON revealed that if CP is not updated the information is communicated to the direct care staff during morning rounds each day.

Based on Record review and staff interview the facility failed to revise the plan of care for as resident that had a recent fall from the bed and had a changes in the use of an antibiotic related to a urinary tract infection for 1 of 3 sample residents (Resident #232). The findings included: Resident #232 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #232 required extensive assistance with bed mobility with the use of 2 staff and was totally dependent for transfers with the use of two staff. Resident #232 had impairments of the both upper and both lower extremities. The MDS further indicated Resident #232 was severely cognitively impaired as evidenced by a Brief Interview for mental status (BIMS) of 3. a) Review of Resident #232 care plan dated 10/26/2016 indicated a problem that Resident #232 was at risk for falling related to decreased mobility, self-care and medication use s/p Cardiovascular accident ([MEDICAL CONDITION]). The goal stated Resident #232 would remain free from injury through next review. The approaches included keep bed in the lowest position at all times. Review of nursing note dated 11/27/16 revealed Resident #232 was found on the floor next to his bed. No skin tears or injuries were noted. Resident #232 complained of pain in his left shoulder. The note continued that Resident #232 vitals were taken and Resident #232 was returned to his bed. Resident #232 was unable to state what happened. Day nurse and family were notified. Nursing would continue to monitor A Review of an electronic Incident report dated 11/27/16 revealed Resident #232 had an unwitnessed fall and was found on the floor beside his bed. The follow up section of the report was blank and not completed. Interview with Nurse #7 on 12/7/16 at 2:51pm revealed when falls occurred it was the responsibility of the shift nurse to complete an incident report. He indicated the facility would initiate a fall huddle. Nurse #7 indicated that prior to the fall huddle staff would put interventions into place such as frequent rounds or bathroom use. Interventions would be implemented based on a review of the fall. Nurse #7 could not recall any interventions put into place following Resident #232 ' s fall. Interview with MDS coordinator on 12/8/16 at 11:14am revealed she was made aware of falls daily from fall huddles. She indicated when a fall occurred the nurse would contact the on call nurse to relay the information regarding the fall. The huddle was to discuss why the fall may have happened and measures at attempt to prevent the fall from occurring in the future. She indicated she included new intervention after analyzing the situation surrounding the fall and the interventions put into place during the huddle. The MDS coordinator stated she was aware of Resident #232 had a fall from the bed. She indicated she could not recall if any interventions were put into place. She stated she had not update the care plan but should have following Resident #232 ' s fall. Interview with DON on 12/7/16 at 10:23 am revealed Resident #232 had one reported unwitnessed fall on 11/27/16. Resident #232 was found on the floor. She indicated the resident indicated he was sitting on the side of his bed and wanted to go somewhere. The resident complained of left shoulder pain. No injuries were noted. The DON stated that at the time of the incident Resident #232 ' s prevalon boots (heel protectors) were still in place. She further stated that was probably the reason he fell attempting to stand up with the prevalon boots on. The DON described Resident #232 as being confused and made poor decisions. The resident had to be reminded to use the call bell for assistance. The DON indicated the follow up report that would have had identified interventions put into place during fall huddle. Interview with NA #6 on 12/7/16 at 11:30am revealed she was made aware of revisions to care plans by the responsible nurse. NA#6 stated she was unaware of any new interventions following Resident #232 fall on 11/27/16. Interview with the DON on 12/7/16 at 3:49pm revealed the responsible nurse would fill out an incident report in the instance a resident had a fall. Following a fall the responsible nurse should be doing a fall huddle with staff about the details surrounding the fall. The nurse should call the call out phone in which a member of management is notified about the fall. The DON stated she could not locate a fall huddle sheet for Resident #232. The DON stated essentially the incident report is what happened at the time of the fall. The fall huddle includes measures put into place based on the details surrounding the fall and immediate interventions put into place following the fall. There was no follow up report competed. The DON stated that the resident ' s cognition and prevalon boots were the main issue for the fall. She further revealed she was responsible for completing the follow up section of the incident report and had not yet competed it. She further revealed falls were discussed at morning meeting and the expectation is that the care plan is updated with interventions to prevent falls. b) Review of Resident #232 ' s care plan dated 10/26/16 revealed a problem of Resident #232 received antibiotics related to urinary tract infection. The Goal stated resident #232 urinary tract infection would resolve without any complications by next review. The approaches included administer antibiotics per MD order, assess for UTI, document characteristics of color, encourage fluids monitor lab work and report abnormal values to NP or MD. Review of Urine Culture dated 10/23/16 indicated Resident #232 had bacteria [MEDICATION NAME] faecalis. Review of physician order [REDACTED]. Special instructions stated give 2 G IM x 1 now. Reconstitute with [MEDICATION NAME] for UTI. Review of Physician order [REDACTED]. The special instructions stated UTI every 12 hours(x30). Review of nursing note dated 10/24/16 revealed positive UA results. Received new order for 1 x dose intramuscularly (IM) antibiotic and an order for [REDACTED].>Interview with Nurse #6 on 12/8/16 at 7:44am revealed Resident #232 started Antibiotic on 10/24/16. Nurse #6 further indicated Resident #232 antibiotics ended on 11/8/16. Interview with MDS coordinator #1 on 12/8/16 at 11:05am revealed she became aware of medication changes through clinical morning meetings. If they finish the antibiotic she indicated she would go to the care pan and discontinue the care plan. Resident #232 antibiotic medication for his UTI had ended on 11/8/16. She further indicated she had not discontinued the care plan or UTI antibiotics use. She revealed it was an oversight. Interview with the DON on 12/8/2016 at 2:50pm revealed it was her expectation that care plans are updated to reflect the resident ' s current plan of care. Residents #232 care plan for the use of antibiotics for a UTI should have been discontinued.