Every finding on record at Elk River Health & Rehabilitation of Fayetteville

Based on review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for two residents (Resident #1 and Resident #29) related to anticoagulant use and two residents (Resident #6 and Resident #28) related to Level II PASARR (Pre-admission Screening and Resident Review) of 15 MDS assessments reviewed.The findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) [NAME] Version 19.1, dated 10/2024, revealed instructions .Health-related Quality of Life .residents covered by Level II PASRR .process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness .High-Risk Drug Classes: Use and Indication Do not code antiplatelet medications such as aspirin .or clopidogrel [antiplatelet medication that prevents blood clots] as anticoagulant [blood thinner] medications . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Diabetes, and History of a Stroke with Paralysis. Review of current Physician Orders revealed .clopidogrel .Tablet, 75 mg [milligram] daily .aspirin .81 mg . Further review revealed Resident #1 did not have an order for an anticoagulant medication. Review of the Medication Administration Record (MAR) for Resident #1 dated 7/1/2025-7/31/2025, revealed Resident #1 did not receive an anticoagulant medication. Review of a quarterly MDS assessment dated [DATE], revealed Resident #1 received an anticoagulant medication. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Traumatic Subarachnoid Hemorrhage, and History of Transient Ischemic Attack. Review of current Physician Orders, revealed .Clopidogrel .75 mg .daily . Further review revealed Resident #29 did not have an order for an anticoagulant medication. Review of the MAR for Resident #29 dated 6/1/2025-6/30/2025 revealed the resident did not receive an anticoagulant medication. Review of an admission MDS assessment dated [DATE], revealed Resident #29 received an anticoagulant medication. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Anxiety Disorder, Major Depressive Disorder, and Schizoaffective Disorder, Bipolar Type. Review of a PASRR dated 6/24/2024, revealed Resident #6 had a PASRR Level 2 Outcome related to a serious mental illness (Schizoaffective Disorder). Review of an annual MDS assessment dated [DATE], revealed Resident #6 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident was not coded for a PASRR Level 2 Outcome. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, and Depression. Review of a PASRR dated 9/21/2023, revealed Resident #28 had a PASRR Level 2 Outcome related to a serious mental illness (Bipolar Disorder). Review of an annual MDS assessment dated [DATE], revealed Resident #28 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident was not coded for a PASRR Level 2 Outcome. During an interview on 9/10/2025 at 12:32 PM, the MDS Coordinator stated Residents #1 and #29 had not received an anticoagulant medication and Residents #6 and #28 had a serious mental illness. The MDS Coordinator confirmed the assessments for Residents #1, #29, #6, and #28 were inaccurate.

Based on facility policy review, medical record review, observation, and interview the facility failed to revise the care plan for 1 resident (Resident #27) of 15 residents reviewed for care plans.The findings include: Review of the facility's policy titled, Goals and Objectives, Care Plans, revised 4/2009, revealed .Care plans will be modified accordingly .Are resident orientated .meet .resident's needs in accordance with the comprehensive assessment .objectives are entered .resident's care plan so that all disciplines have access to .information .are reviewed and revised .change in the resident's condition . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Diabetes, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #27 scored 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #27 required partial/moderate assistance with eating. Review of the comprehensive care plan for Resident #27 revised 8/15/2025, revealed .Resident is independent with eating at this time . During an interview on 9/8/2025 at 2:25 PM, Certified Nursing Assistant (CNA) D stated Resident #27 was dependent upon staff with eating. During an interview on 9/9/2025 at 7:46 AM, Licensed Practical Nurse (LPN) E stated Resident #27 was dependent upon staff with eating. During an interview on 9/10/2025 at 12:19 PM, LPN MDS Coordinator confirmed Resident #27's care plan had not been revised to reflect the resident was dependent on staff with eating. During an interview on 9/10/2025 at 12:20 PM, the Director of Nursing confirmed Resident #27's care plan had not been revised to reflect the resident was dependent on staff with eating.

Based on facility policy review, temperature log review, facility documentation review, observation, and interview, the facility failed to minimize the potential for foodborne illness transmission by not properly cleaning and sanitizing the inner components of the ice machine for residents in the facility. The facility failed to store milk at the appropriate temperature at or below 41 degrees Fahrenheit (F) for residents who consume milk. The findings include: Review of the undated facility policy titled, Food Receiving and Storage, revealed, .Foods shall be received and stored in a manner that complies with safe food handling practices .Refrigerated foods must be stored below 41 [degrees] F unless otherwise specified by law .Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements . Review of the facility policy titled FOOD STORAGE, dated 12/20/2019, revealed, .Improper storage of Time/Temperature Controlled for Safety (TCS) foods can affect you or even worse, get a resident sick .These foods must be maintained at the proper temperature, typically 41 [degrees] F of [or] below . Review of the TELS [maintenance tracking system] report dated 6/7/2024 revealed, .Ice Machine: Check filters (if present), clean coils, sanitize interior, delime [to free from lime] as necessary. Marked done on time by [Named Maintenance Director] .Check water filter (if present) .Clean Coils .Re-install panel cover and return unit to service .Sanitize Interior 1. Sanitize interior of machine per manufacturer's instructions. 2. Clean out and sanitize the ice bin .Clean Exterior .Date service tag when service is completed . Observation and interview on 7/8/2024 at 10:18 AM revealed the Dietary Manager (DM) conducted a temperature check on a carton of milk in the cooler. The milk temperature was 45 degrees F. The DM confirmed that the milk's temperature should be at or below 41 degrees F. Observation and interview on 7/8/2024 at 10:41 AM with the DM revealed the ice machine on the 200 Hall had yellow stains on the inside cover panel with dark specks on the bottom of the panel dripping into the ice. The DM was asked who is responsible for cleaning and providing maintenance to the ice machine and were there any other ice machines in the building. The DM stated that maintenance is responsible for cleaning and providing maintenance to the ice machine and that the 200 Hall ice machine is the only ice machine in the building. Observation and interview on 7/8/2024 at 11:40 AM revealed, the Regional Clinical Director of Nurses stated that the yellow stains with dark specks should not be in the ice machine. During an interview on 7/10/2024 at 8:03 AM revealed, the Maintenance Director stated that he is responsible for cleaning and checking the ice machine every 3 months. He stated he typically depends on the facility's staff to let him know in between times if anything is wrong with the ice machine. The Maintenance Director stated that no one had notified him about the ice machine needing to be cleaned before Monday [7/8/2024] of the state survey. The Maintenance Director stated he uses TELS to track the servicing for the ice machine and that the last service was done at the beginning of June 2024. During an interview on 7/10/2024 at 7:26 PM, the Administrator stated that she expects her staff to notify the Maintenance Director when the ice machine needs to be cleaned or if there are any mechanical issues.

Based on facility policy review, medical record review, observation and interview, the facility failed to maintain a complete and accurate medical record for 1 (Resident #9) of 4 residents reviewed for administration of controlled drugs. The findings include: Review of the facility policy titled, Controlled Substances, dated 4/2019 revealed, .Controlled substances are reconciled upon .administration .The nurse administering the medication is responsible for recording .Name, strength and dose of the medication .Time of administration .Method of administration .Quantity of the medication remaining .and Signature of nurse administering medication . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnosis which included Morbid Obesity and Muscle Weakness. Review of the Medication Administration Record (MAR) dated July 2024 revealed an order for Gabapentin 300 mg (milligram) capsule one capsule by mouth three times a day for pain at 7:00 AM, 1:00 PM, and 7:00 PM. Continued review of the MAR revealed an order for Percocet 5-325 mg tablet one tablet by mouth every 6 hours as needed for pain. During an observation of medication administration on 7/9/2024 at 8:30 AM, a random narcotic drug count was performed with Licensed Practical Nurse (LPN) G. The narcotic count on 7/9/2024 at 8:32 AM, revealed Resident #9 had 1 Gabapentin 300 mg capsule and 1 Percocet 5-325 mg tablet not accounted for on the narcotic count sheet. LPN G stated, Oh, I was going to sign those out, but I forgot. I gave them at 7:00 AM. LPN G was asked when a controlled drug should be signed out of the narcotic count book. LPN G stated, I should have signed it out as soon as I pulled it out to give. Review of the MAR revealed Gabapentin 300 mg and Percocet 5-325 mg tablet had been administered as given at 7:00 AM prior to this narcotic count. During a telephone interview on 7/9/2024 at 2:22 PM, the Pharmacist stated, The nurse should have signed out the narcotic as she gave the medications.

Based on facility policy review, observations, and interviews, the facility failed to ensure food was handled in a sanitary manner in the kitchen on 4 of 4 observations, having the potential to affect all residents. The findings include: Review of the facility's policy titled, Food Preparation and Service, revised 4/2019, revealed, .Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices .Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of infection .Food and nutrition services staff wash their hands before serving food to residents .Gloves are worn when handling food directly and changed between tasks . Review of the facility's policy titled, Infection Prevention and Control Program, revised 10/2018, revealed, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Observations and interviews in the kitchen on 4/18/2022 at 12:07 PM, 12:09 PM and 12:10 PM, the cook was plating food on the tray line and she touched the black eyes peas with her gloved fingers to keep them from rolling off of the plate, then picked up a piece of cornbread and placed it on the plate. The Cook and Dietary Manager confirmed she should use tongs or other utensils and should not touch the food with gloved hands. Observation and interview in the kitchen on 4/18/2022 at 12:13 PM, in the presence of the Dietary Manager, the Dietary Aide picked up a slice of bread with her gloved hands, spread mayonnaise on the bread, then placed the bread on the bare stainless steel prep table. The Dietary Manager confirmed the Dietary Aide should not have touched the bread with her gloved hands, and should have placed the bread on a tray or plate, not the prep table.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 7 sampled residents (Resident #13 and Resident #22) were treated in a dignified manner during the lunch meal on 4/18/2022. The findings include: Review of the facility's policy titled, Resident Rights, revised 12/2016, revealed, .Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence .b. be treated with respect, kindness, and dignified . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with readmission on 12/25/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 required extensive assistance with 1 person assist with eating. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with readmission on 3/17/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual MDS assessment dated [DATE], revealed Resident #22 required supervision with 1 person assist with eating. Observation in the dining room on 4/18/2022 during the mid-day meal at 12:33 PM to 12:51 PM, revealed Resident #13 was seated at table 3 with 1 other resident. Resident #13 was not served a meal tray until 9 minutes after the other resident. Continued observation revealed a resident seated at table 4 was served a meal tray prior to Resident #13 receiving her tray. Continued observation revealed Resident #22 was seated at table 2 with another resident. Continued observation revealed Resident #22 was served her meal tray 6 minutes after the other resident was served. Continued observation revealed a resident seated at table 3 was served a meal tray prior to Resident #22 receiving her meal tray. During an interview on 4/18/2022 at 12:51 PM, Licensed Practical Nurse (LPN) #1 confirmed Resident #13 and Resident #22 did not receive their meal trays at the same time as the residents sitting at the tables with them. During an interview on 4/19/2022 at 1:23 PM, the Director of Nursing stated the dining process was for the staff to pass out the trays to all the residents sitting at the same table at the same time. She stated, I expect them to be served per table. Each table should be served together.

Based on facility policy review, medical record review, observation and interview, the facility failed to develop and implement a person-centered care plan for 1 of 25 sampled residents (Resident #7) for care plan development and implementation. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, revealed, .A comprehensive, person-centered care plan that includes .the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .Reflect treatment goals .Aid in preventing or reducing decline in resident's functional status .Enhance the optimal functioning by focusing on a rehabilitative program .Reflect current problem areas and conditions . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status (SCIS) Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 required extensive to total assistance with activities of daily living (ADLS), receiving Occupational Therapy (OT) services. Review of the Quarterly Note for MDS dated [DATE] revealed Resident #7 had contractures of the right and left knees upon admission. Review of the Care Plan for Resident #7 dated 2/7/2022 revealed, Resident #7 had no identified contractures or interventions such as hip/knee orthosis (orthotic therapy for positioning or progressive extension stretch therapy to reverse adduction contracture) on her care plan. Observation in the activity/dining room area on 4/18/2022 at 10:58, Resident #7 was in a tilt-in-space positioning chair with a wedge cushion under both legs/knees and with hip/knee abduction orthosis prevention in place. Observation in activity/dining area on 4/19/2022 at 8:23 AM Resident #7 was in a tilt-in-space positioning chair with abduction orthosis in place and pillow under both legs and knees with eyes closed. During an interview on 4/19/2022 at 12:35 PM, the MDS Nurse confirmed Resident #7 had no interventions on her care plan for the contracture or use of orthosis. Continued interview, the MDS Nurse verified Resident #7 did had a SCIS assessment completed on 2/7/2022 and did not have limited range of motion indicated on the assessment.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control procedures when performing wound care for 1 of 2 sampled residents (Resident #5) observed for wound care. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, revised 10/2018, revealed, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Review of the facility's policy titled, Wound Care, revised October 2010 revealed, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Put on exam glove. Loosen tape and remove dressing .Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly .Put on gloves . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR (Treatment Administration Record) for Resident #5 dated April 2022, revealed documentation the treatment to the Stage 4 pressure injury to the right buttock was performed as ordered. Review of the Care Plan for Resident #5 dated 2/21/2022, revealed, .I have a pressure ulcer on my right buttocks. Stage 4 .Treatment as directed by MD [Medical Doctor]/NP [Nurse Practitioner] . Observation in Resident #5's room on 4/19/2022 at 11:08 AM, revealed the Treatment Nurse cleansed the pressure injury on the right buttock with Normal Saline and a 4 x 4 gauze. She then continued performing the prescribed treatment without sanitizing her hands or donning clean gloves. During an interview on 4/19/2022 at 11:18 AM, the Treatment Nurse confirmed she should have sanitized her hands and donned clean gloves after cleaning Resident #5's wound. During an interview on 4/19/2022 at 11:20 AM, the Director of Nursing confirmed the Treatment Nurse should have sanitized her hands and donned clean gloves after cleaning Resident #5's wound and before applying a clean dressing.

Based on policy review, medical record review, observation, and interview, the facility failed to promote care that maintained residents' dignity, respect, and quality of care when staff failed to provide a dignity bag for 1 of 2 (Resident #41} sampled residents reviewed with catheters. The findings include: The facility's Quality of Life-Dignity policy revised (MONTH) 2009 documented, .Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by .Helping the resident to keep urinary catheter bags covered . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].FOLEY CATH (catheter) .W (with) / CATH CARE .EACH SHIFT . Observations in Resident #41's room on 6/24/19 at 3:59 PM, 6/25/19 at 7:40 AM, and 1:06 PM, revealed Resident #41 was observed lying in the bed with an indwelling urinary catheter draining yellow urine into a bed side drainage bag with a plastic leaf that did not cover the bedside drainage bag and was visible to others from the resident's door. Interview with Licensed Practical Nurse (LPN) #1 on 6/25/19 at 1:10 PM, at the Memory Care Nursing Station, LPN #1 was asked if it was appropriate for Resident #41's drainage bag to be uncovered. LPN #1 stated, .No . Interview with the Director of Nursing (DON) on 6/25/19 at 3:15 PM, at the Nurses' Station, the DON was asked if it was appropriate for an indwelling catheter bag to be uncovered. The DON stated, No.

Based on policy review, medical record review, and interview, the facility failed to follow the interventions for falls accordance with the plan of care for 2 of 15 (Resident #13 and #41) sampled residents reviewed. The findings include: 1. The facility's Care Planning-Interdisciplinary Team policy revised (MONTH) 2013 documented, .Identifying problem areas and their causes, and developing intervention that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process . 2. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 6/16/19 documented, .Fall mats beside bed at all time . Observations in Resident #13's room on 6/24/19 at 4:37 PM and 6/25/19 at 8:24 AM, revealed Resident #13 was in her bed with a stuffed animal and was pleasantly confused. There were no fall mats on the floor beside her bed. Interview with the Director of Nursing (DON) on 6/25/19 at 3:20 PM, in the Conference Room, the DON was asked should Resident #13 have fall mats in place. The DON confirmed the fall mat should be in place. 3. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 4/5/18 and updated 6/20/19 documented, .Keep protective helmet on head at all times .Observe frequently to ensure it is in place and resident hasn't removed and hid it .Fall mats on sides of bed on Floor . Observations in the Locked Unit Dining Room on 6/24/19 at 11:41 AM, revealed Resident #41 was seated with her legs over the side of her wheelchair. She was not wearing a helmet. Observations in Resident #41's room on 6/24/19 at 3:59 PM and 6/25/19 at 7:40 AM, revealed Resident #41 in her bed asleep. There were no fall mats on the floor beside her bed. Interview with Licensed Practical Nurse (LPN) #1 on 6/25/19 at 1:10 PM, at the Nurses' Station, LPN #1 was asked should Resident #41 have had her helmet and fall mats in place. LPN #1 stated, Yes.

Based on policy review, medical record review, observation, and interview, the facility failed to follow physician diet orders and the care plan for supplements for 1 of 4 (Resident #36) sampled residents reviewed for weight loss. The findings include: 1. The facility's Weight Assessment and Intervention policy revised (MONTH) 2008 documented, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . The facility's Care Plans, Comprehensive Person-Centered policy revised (MONTH) (YEAR) documented, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . 2. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 3/29/16 and reviewed 6/12/19 documented, .Assist/feed resident meals as she will allow .Offer to substitute if resident refuses. Document and report any refusals .Observe and document meal intake per facility protocol .Offer finger foods .Supplements as ordered and document per facility protocol .Follow RD (Registered Dietician)/Dietary suggestions .Ice cream with all meals . The physician's orders [REDACTED].Shakes tid (three times daily) w (with) /meals (wt (weight) loss) . The physician's orders [REDACTED].Ice cream w/all meals . The CNA (Certified Nursing Assistance) -ADL (Activities of Daily Living) Tracking Form dated 5/2019 failed to document meal intake on 5/3/19 and 5/9/19. The CNA-ADL Tracking Form dated 5/2019 failed to document snacks were offered on 5/3/19, 5/9/19, 5/17/19, and 5/26/19. The CNA-ADL Tracking Form dated 5/2019 failed to document dietary substitutes were offered on 5/1/19, 5/3/19, 5/5/19, 5/10/19, 5/11/19, 5/12/19, 5/17/19, and 5/28-5/31/19. The ADL Flow Record dated (MONTH) 2019 documented on 6/24/19 Resident #36 received oversight, encouragement or cueing with setup help only and consumed 25% of her lunch meal. The ADL Flow Record dated (MONTH) 2019 documented on 6/24/19 Resident #36 received Extensive assistance and One person physical assistance and consumed 25% of her dinner meal. 3. The breakfast, lunch, and dinner meal tickets dated 4/21/19 documented chocolate ice cream. The meal tickets did not reflect Resident #36 had a shake with all meals per the physician orders. The breakfast and lunch meal ticket dated 6/20/19 did not reflect Resident #36 had a shake or ice cream with all meals. 4. Observations in Resident #36's room on 6/24/19 at 12:42 PM, revealed Resident #36 was served a lunch meal of meat loaf, green beans, mashed potatoes, (2) rolls, and chocolate milk. Resident #36 was observed groping with her hands for her lunch tray. No straws were provided for her tea or milk. Resident #36 drank the milk out of the carton. Resident #36 was not cued, encouraged or assisted. A shake and ice cream was not on her lunch tray and alternatives were not offered. At 1:06 PM, Resident #36 had consumed 100% of the chocolate milk but did not eat her meal. Observations in Resident #36's room on 6/25/19 at 12:32 PM, revealed Resident #36 was served a lunch tray with a glass of chocolate milk, glass of tea, mashed potatoes, macaroni and cheese, chopped chicken, a roll, pudding, and mixed vegetables. Resident #36 groped for her utensils and felt for the food. She picked up her glass of tea and took a sip and then set the tea glass in her pudding. While trying to put a straw in her tea glass, she spilt tea on the over-bed table and bed linens. She picked up a comb and straw and placed the straw and comb back down on the table and dipped her fingers in the pudding. She groped for the plate and quit several times. This surveyor asked if she wanted her chocolate milk and Resident #36 replied, yes, but I can't find it. Resident #36 drank all of her chocolate milk and fumbled the empty glass back to the over-bed table upside down. Ice cream was not on her tray. Resident #36 was not cued, encouraged or assisted and an alternative was not offered. 5. Telephone interview with the Registered Dietician (RD) on 6/25/19 at 2:12 PM, the RD was asked how would the kitchen staff know what her recommendations were or about changes in a resident's diet. The RD stated, .I talk with the food manager myself or pass the word to the nurses .it's up to the facility to make sure the staff contacts the physician . The RD was asked how did she know the resident was getting her recommendations. The RD stated, It (recommendations) should be on the meal tickets . The RD was asked if Resident #36 should have ice cream and shakes on her meal ticket. The RD stated, Yes. The RD was asked where the supplement intake was charted. The RD stated, .should be charted on the MAR Medication Administration Record) .ice cream is charted as part of her meal intake, same with the shakes . Interview with the Dietary Manager on 6/25/19 at 2:41 PM, in the Independent Dining Room, the Dietary Manager was asked if she visits Resident #36. The Dietary Manager stated, at least every week . The Dietary Manager was asked how her kitchen staff knew what each resident in the facility should be served. The Dietary Manager stated, They go by the meal tickets. The Dietary Manager was asked if Resident #36 should be receiving shakes and ice cream with every meal per the physician's orders [REDACTED]. The Dietary Manager was shown Resident #36's meal tickets and was asked if the ice cream and shakes were on the meal tickets. The Dietary Manager stated, No, we started using a new system last week but my staff knows this resident is supposed to be getting shakes and ice cream. Interview with the Director of Nursing (DON) and the MDS Coordinator on 6/26/19 at 3:52 PM, the DON was asked where were the recommended supplements should be charted. The DON stated, .If the supplements are provided with the meals, they are charted as a percentage with the meals . The DON was asked how would she know how much of the supplements are being consumed. The DON stated, .There is no way to break that down . The DON was asked how would she know the supplements are effective if they are not charted separately from the meal. The DON stated, .If the weights are stable and if they are gaining . The DON was asked if she expected the staff to offer assistance during meals. The DON stated, Yes . The DON was asked if she expected staff to offer an alternative. The DON stated, Yes. The DON was asked if the physician orders [REDACTED]. The DON stated, Yes. The DON and MDS Coordinator were shown the ADL Flow sheets for 6/24/19 lunch and asked if the documentation that Resident #36 received supervision, encouragement or cueing and set up only, and if the resident only drank her chocolate milk, would 25% meal consumption be accurate. The DON stated, No. The DON and MDS Coordinator were shown the ADL Flow sheet for 6/24/19 dinner and 6/25/19 lunch, and asked if the resident only drank her chocolate milk, would 25% meal consumption be accurate. The DON stated, No. The DON and the MDS Coordinator were shown the CNA-ADL Tracking Form dated (MONTH) 2019 and was asked if the documentation was complete. The MDS Coordinator stated, .it's (documentation) kinda sparse .

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing staff failed to prevent the catheter tubing from touching the floor for 1 of 3 (Resident #41) sampled residents reviewed with catheters. The findings include: The facility's Catheter Care, Urinary policy revised (MONTH) 2014 documented, .Be sure the catheter tubing and drainage bag are kept off the floor . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].FOLEY CATH (catheter) .W (symbol for with) / CATH CARE .EACH SHIFT . Observations in the Locked Unit Dining Room on 6/24/19 at 11:41 AM, revealed Resident #41 was seated with her legs over the side of her wheelchair, her indwelling catheter was draining into a bedside drainage bag, and the bottom of the bag was touching the floor. Observations in Resident #41's room on 6/24/19 at 3:59 PM, 6/25/19 at 7:40 AM, and 1:06 PM, revealed Resident #41 was in the bed asleep on her left side. Her indwelling catheter was draining into a bedside drainage bag, and the bottom of the bag was touching the floor. Interview with Licensed Practical Nurse (LPN) #1 on 6/25/19 at 1:10 PM, in the Memory Care Nurses' Station, LPN #1 was asked if it was appropriate for Resident #41's drainage bag to be on the floor. LPN #1 stated, .No . Interview with the Director of Nursing (DON) on 6/25/19 at 3:15 PM, at the Nurses' Station, the DON was asked if it was appropriate for an indwelling catheter bag to be on the floor. The DON stated, No.

Based on policy review, observation, and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by 1 of 7 (Cook #1) staff members hair was not completely restrained, dirty seal and ice build up in the freezer, carbon build up on a skillet, a dirty air vent, water dripped on clean dishes in a dishrack and 4 of 12 (Social Worker, Licensed Practical Nurse (LPN) #1, Speech Therapist #1, and Admissions Director) staff members failed to perform proper hand hygiene during dining. The facility had a census of 46, with 44 of of those residents receiving a tray from the kitchen. The findings included: 1. Review of the facility's Food Preparation and Service policy revised (MONTH) 2014 documented, .Dietary staff shall wear hair restraints .so that hair does not contact food . Review of the facility's Handwashing/Hand Hygiene policy revised (MONTH) (YEAR) documented, .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .Before and after assisting a resident with meals . 2. Observations in the kitchen during initial tour on 8/6/18 beginning at 12:30 PM, with the Dietary Manager revealed the following: a. Cook #1's hair was not completely restrained. b. A black substance was on the back seal of the freezer with a large amount of frozen ice on the back and both sides of the freezer. Interview with the Dietary Manager on 8/6/18 at 12:33 PM, in the kitchen, the Dietary Manager confirmed the black substance on the back seal of the freezer and the ice build up in the freezer. c. A skillet was sitting on the stove with a black substance on the inside of the skillet. Interview with the Dietary Manager on 8/8/18 at 12:36 PM, in the kitchen, the Dietary Manager was asked if there was carbon build up in the skillet. The Dietary Manager stated, Um'huh (Yes). d. An air vent in the ceiling near the tray line had a black substance around the vent and on the vent grids. Observations in the kitchen on 8/7/18 beginning at 4:55 PM revealed the following: a. Cook #1's hair was not completely restrained. b. A black substance on the back seal of the freezer with a large amount of frozen ice on the back and both sides of the freezer. Observations in the kitchen on 8/7/18 beginning at 5:35 PM revealed the following: a. Cook #1 was serving food from the tray line with hair not completely restrained. b. An air vent in the ceiling near the tray line had black substance around the vent and on the vent grids. A drop of water fell from the vent and landed on a dishrack of clean dishes. The staff removed 3 dishes from the dish rack and left 12 bowls and 6 cups on the dishrack. Interview with the Registered Dietician (RD) on 8/7/18 at 5:40 PM, in the kitchen, the RD was asked if the vent was dirty. The RD stated, Not sure. The RD was asked if was acceptable for water from the air vent to drip on the dishware. The RD stated, I'm not sure. Interview with the Maintenance Director on 8/7/18 at 5:45 PM, in the kitchen, the Maintenance Director was asked about the vent. The Maintenance Director stated, It is dust. Interview with the RD in 8/8/18 at 2:15 PM, in the kitchen, the RD was asked if hair should be completely covered. The RD stated, Yes, ma'am. The RD was asked, if the air vent should be dirty near the tray line. The RD stated, There was some dust on there and they cleaned it. The RD was asked should the dust have been there. The RD stated, No ma'am. Interview with the Administrator on 8/8/18 at 2:35 PM, in the DON office, the Administrator was asked if water dripped from a ceiling vent on a dishrack of clean dishware, what would you expect. The Administrator stated, Need to send (dishware) to the dishwasher and be washed again. 3. Observations in the Dining room on 8/6/18 beginning at 5:20 PM, revealed the Social Worker served Resident #18's tray, set up the tray, and touched Resident #18's shoulder with her hand, served Resident #23's tray, removed the plate cover and touched the lock on Resident #23's wheelchair without performing hand hygiene. The Social Worked went and moved the chair and sat to feed Resident #23 without performing hand hygiene. The Social Worker dropped some food on Resident #23's clothing, moved his wheelchair, got a washcloth from the Maintenance Director, then cleaned Resident #23's shirt, and assisted to feed Resident #23 without performing hand hygiene. Observations in the Dining room on 8/6/18 beginning at 5:20 PM, revealed Licensed Practical Nurse (LPN) #1 served Resident #14's tray and completed tray set up, moved Resident #14's wheelchair, and assisted to feed Resident #14 without performing hand hygiene. LPN #1 repositioned Resident #14's arm and leg then fed him without performing hand hygiene. LPN #1's antibacterial soap fell out of her pocket onto the floor. The Maintenance Director picked up the antibacterial soap and placed it on a cabinet. LPN #1 went to the cabinet and used the antibacterial soap and stated It fell out of my pocket. LPN #1 repositioned Resident #14's legs, repositioned him in the wheelchair, then fed Resident #14 without performing hand hygiene. Observations in the Dining room on 8/7/18 at 12:45 PM, revealed Speech Therapist #1 moved a chair and sat to feed Resident #10 without performing hand hygiene. Observations in the Dinning room on 8/718 at 12:47 PM, revealed the Admissions Director moved the chair and sat to feed Resident #20 without performing hand hygiene. Observations In Resident #7's room on 8/8/18 at 8:35 AM, revealed the Admissions Director brought a chair into Resident #7's room, moved the chair, sat it on the left side of the bed, then moved it to the right side of the bed. LPN #2 picked up a dirty gown and removed it from the overbed table and placed it in a linen bag. The Admissions Director moved the tray from the bedside table and placed it on the overbed table, then moved Resident #7's pillow and repositioned her in the bed without performing hand hygiene. Interview with the Director of Nursing (DON) and the Regional Nurse Consultant on 8/8/18 at 1:50 PM, in the DON office, the DON was asked would you expect staff to perform hand hygiene before serving trays and feeding residents. The DON stated, Um'huh. The DON was asked if it was acceptable to touch objects in the environment and then feed residents. The DON stated, No. The DON was asked if antibacterial soap had been dropped on the floor should it be used while feeding a resident. The DON stated, No. The DON was asked if a breakfast tray should be placed on the overbed table after a dirty gown had been removed. The DON stated, Un'huh (No). The DON was asked if it was acceptable to touch chairs, wheel chairs, and feed residents without performing hand hygiene. The DON stated, No.

Based on policy review, observation, and interview, the facility failed to ensure the environment was clean, comfortable and sanitary as evidenced by a raised toilet seat with a large amount of rust and paint chipping off the legs, an uncovered and unlabeled toothbrush, a cabinet door in a bathroom would not close completely and water running from the faucet in the bath tub, a toilet paper holder detached from the wall on the left side with a large amount of rust on the entire holder, and blue duct tape wrapped around a toilet seat that was peeling off in 5 of 37 (room [ROOM NUMBER], 129, 130, 131 and 132) resident rooms. The findings included: 1. The Maintenance Service policy revised (MONTH) 2009 documented, .Maintain the building in good repair .Providing routinely scheduled maintenance service to all areas . 2. The Teeth, Brushing policy revised (MONTH) (YEAR) documented, .Clean your equipment and return it to its designated storage area . 3. Observations on 3 of 3 days of the survey revealed the following: Observations in room [ROOM NUMBER] on 8/6/18 at 12:31 PM, 8/6/18 at 5:15 PM, 8/7/18 at 10:53 AM, and 8/8/18 at 1:22 PM, revealed a raised toilet seat in the bathroom with a large amount of rust and paint chipped down the legs of the seat. Observations in room [ROOM NUMBER] on 8/6/18 at 1:17 PM, 8/6/18 at 5:18 PM, 8/7/18 at 11:09 AM, and 8/8/18 at 1:25 PM, revealed running water from the faucet in the bath tub, a cabinet in the bathroom that would not completely close, an opened tube of toothpaste and a toothbrush that were uncovered and not labeled lying on the bathroom sink. Observations in room [ROOM NUMBER] on 8/6/18 at 1:19 PM, revealed a tube of toothpaste and a toothbrush uncovered and not labeled lying on the bathroom sink. Observations in room [ROOM NUMBER] on 8/6/18 at 12:40 PM, 8/6/18 at 5:23 PM, 8/7/18 at 11:12 AM, and 8/8/18 at 1:30 PM, revealed a toilet paper holder detached from the wall on the left side with a large amount of rust completely covering the entire sides of the holder, and a toilet seat wrapped halfway with blue duct tape that was peeling off the toilet seat. Observations in room [ROOM NUMBER] on 8/6/18 at 12:42 PM and 8/6/18 at 5:27 PM, revealed a toothbrush on top of the paper towel holder wrapped in tissue with the top uncovered and not labeled. Interview with the Maintenance Director on 8/7/18 at 12:06 PM, at the Nursing Station on the Memory Lane unit, the Maintenance Director was asked how often are the residents' rooms checked. The Maintenance Director stated, We have angel rounds .certain people have certain rooms .we walk the hall daily .all department heads check the rooms daily . The Maintenance Director was asked if it was acceptable to have a cabinet in the resident bathroom that would not completely close, duct tape wrapped around the toilet seat and a toilet paper holder hanging off the wall that was completely rusty. The Maintenence Director stated, No it's not acceptable .the hinge looks like it's bent on the cabinet . Interview with the Director of Nursing (DON) on 8/8/18 at 2:22 PM, in the Conference room, the DON was asked how often are the rooms checked in the unit. The DON stated, We do angel care rounds Monday through Friday .with the department heads .the Manager on weekend do the entire building . The DON was asked what they checked. The DON stated, Call light in reach .the room is in good repair .rooms not cluttered .condition of the patients .bed in low position . The DON was asked if it was acceptable to have a raised toilet seat with rust on it with the paint chipping off, toothbrushes left uncovered and on the bathroom sink, toothpaste lying on the bathroom sink, cabinet door not closing completely, water running in the resident bath tub, toilet paper holder with a large amount of rust and detached from the wall, and duct tape wrapped around the toilet seat in the resident shared bathrooms. The DON stated, No it's not acceptable .toothpaste should be put away .toothbrushes should be covered and labeled .

Based on review of the residents' trust account balances and interview, the facility failed to ensure trust fund balances did not exceed the Supplemental Security Income (SSI) limit in their trust fund for 1 of 35 (Resident #54) resident trust accounts reviewed for the quarter of 4/1/16-6/30/17. The Findings included: Review of Resident #54's RESIDENT FUND MANAGEMENT SERVICE STATEMENT for the period of 4/1/17 through 6/30/17 documented the following: 4/1/17 balance was $2142.68 5/1/17 balance was $2877.73 6/1/17 balance was $3612.80 6/30/17 balance was $2347.91 Interview with the Administrator on 7/25/17 at 9:20 AM in the Business office , the Administrator was asked about the account balance for Resident #54 and the Administrator stated, .She is Medicaid .she is over the Medicaid limit of $2,000.00 . Interview with the Receptionist on 7/25/17 at 9:40 AM, in the Conference room, the Receptionist stated, .She gets Medicaid, she only draws SSI. The Business Office Manager contacted the EOGS (eligibility operations group spreadsheet) as why her income is so high. They did not call her back. She has no liability because she draws SSI. The (named group coordinator) came 3 months ago and left a folder and said she may start owing liability but never has updated in Tennessee, in June we paid $2,000 burial insurance . Interview with the Administrator on 7/26/17 at 12:17 PM, in the Administrator office, the Administrator was asked if it was acceptable for a resident to have a balance of over $2,000.00 under the Medicare guidelines and the Administrator stated, .No .

Based on facility policy review, medical record review, facility investigation review, and interview, the facility placed 1 (Resident #2) resident of 4 residents reviewed inside the secured unit against his will. The facility failed to provide a least restrictive alternative for the resident prior to being secluded from his room and familiar residents. The findings included: Review of a facility policy titled Abuse Prevention/Reporting Policy and Prevention dated 2013 revealed, .Residents must not be subjected to abuse by anyone .Abuse is defined as .unreasonable confinement .separation of a resident against the resident's will .When a resident is secluded for more than 1 hour the following must be documented in the resident's medical record: 1. The symptoms leading to the seclusion. 2. The root cause of the symptoms .3. Alternative interventions prior to the seclusion . Medical record review revealed Resident #2 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review of a 14 day Minimum (MDS) data set [DATE] revealed the resident had disorganized thinking that fluctuated daily, had no behaviors, and did not wander. His Brief Interview for Mental Status score was 11/15 indicating moderate cognitive impairment. The resident required limited assistance of 1 person transfers, had no extremity impairments, and used a wheelchair for ambulation throughout the facility. Medical record review of the Risk of Elopement/Wandering Review assessment revealed on 8/19/16, 10/26/16, 11/10/16. and 11/30/16 Resident #2 was assessed as not at risk for elopement/wandering at this time. Continued review revealed documentation on 11/10/16 of .voices desire to go home but is aware of need for therapy services . Review of a facility investigation dated 9/29/16 revealed Resident #2 stated, .that he was sitting at the door of the locked unit trying to figure out the code to the door . Continued review revealed, .The resident is alert and oriented x (times) 3 with some confusion noted at times .The facility does have video cameras in the hallway .it was very clear by reviewing the camera by the locked unit door .the resident was not combative in any way .The resident was viewed self-propelling his wheelchair back into and back up the hallway . Continued review revealed the facility reviewed the video from 2:00 PM- 4:00 PM of the resident in the secured unit hallway and at the locked door. Review of a telephone statement made by Licensed Practical Nurse (LPN) #1 on 9/29/16 revealed on 9/18/16 another nurse reported to her the .pt. (patient) was sitting at doorway which is not unusual. The weekend supervisor .came to memory lane (secured unit) and stated (Resident #2) is trying to get out of the door. (LPN #1) then spoke with patient and took him to memory lane so he could be watched closer. He stayed in the back until his family arrived and they visited with him in his room .This was the 1st behavior episode that this nurse had been involved in with this patient. Telephone interview with LPN #1 on 12/6/16 at 12:30 PM revealed the LPN confirmed her written statement after it was read to her by the surveyor. The LPN confirmed she had taken Resident #2 to the secured unit after a nurse and the supervisor told her he was exit seeking. The LPN stated the nurse worked PRN (as needed) and the supervisor was new and neither one knew the resident sat at the door frequently. Continued interview revealed the LPN was caring for residents on the secured unit as well as residents on the unsecured unit and she placed Resident #2 in the secured unit so she could visualize him better. When asked if the resident wanted to be in the secured unit the LPN stated, He was upset at first and was ranting and raving and yelling that he wanted to call the cops. When I asked him why, he said because you got me back here. The LPN stated she told the resident I can't watch you if you get outside and roll down the hill into the road. The nurse stated, His family came to visit shortly after that, and they took him back to his room (unsecured unit) to eat lunch. When they were done visiting the family brought him back to me in the secured unit. Continued interview revealed the LPN stated the time frame was approximately 1:30 PM to 5:30 or 6:00 PM. During this time was when the resident was visualized on the video camera in the hallway by the door banging on it and pushing the buttons to try to get out. 2 PM-4 PM was quiet time for the resident's who lived in the secured unit. The LPN reported she explained that to the resident and encouraged him to take a nap in an empty room which he did for 45 minutes. The LPN was asked if she offered to take the resident outside and she stated, I don't remember him going outside. Medical record review revealed no documentation regarding the root cause of the symptoms that caused the resident to want to go outside, and no alternative interventions prior to placing the resident in the secured unit were found. Interview with the Director of Nursing (DON) on 12/6/16 at 12:45 PM in the Admission's Office confirmed Resident #2's room was #126 A and was not located in the secured unit. Continued review revealed the DON stated he tried to follow family out the door so the nurse put him in Memory Lane for a couple of hours. I personally didn't think he was trying to leave the grounds. I think he wanted to go outside cause he liked to sit outside. The DON was asked if anyone offered to take the resident outside, or sit with him, and the DON stated, I don't know, but we have hospitality aides here now, and Activities is here on the weekends too. The DON confirmed no other interventions were attempted prior to placing Resident #2 in the secured unit against his will. The facility failed to protect the resident from involuntary seclusion.

Based on medical record review, observation, and interview the facility failed to provide an environment that promoted and enhanced the dignity for 1 (Resident # 4) resident of 4 residents reviewed. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Continued review of a 14 day Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, required extensive assistance of 2 people for bed mobility, transfers, hygiene and toileting, was unsteady on her feet, and only able to stabilize herself with assistance from staff, and was occasionally incontinent of bowel and bladder. Observation of Resident #4 on 12/7/16 in room [ROOM NUMBER] A at 8:45 AM revealed the resident was alert, laying on her back on a mattress on the floor in a hospital gown. Her hair was disheveled, and she had a bruise to her left eyelid. A fall mat was on each side of the mattress. The mat on the left side of the resident was torn in 3 places with dark brown saturated debris visible. A small pink plastic water pitcher and a small clear plastic cup was at the head of the bed to the right of the resident. A straight back chair and an over bed table were in the far corner of the room as well as a small table with a small TV on it. The call light was to the left of the resident on the floor. The resident attempted to get up off the mattress and she was not wearing any briefs and there was no pad underneath her on the mattress. Continued observation revealed there were no personal items, pictures on the walls, or decor of any kind in the room. Resident #2 was asked if she was still having diarrhea and she stated, Yes. When questioned about the bruise to her eye, she stated, I don't know. Interview with Licensed Practical Nurse (LPN) #2 on 12/7/16 at 9:00 AM in the Memory Lane Nurse Station revealed the bruise was found yesterday and was under investigation. Continued interview with the LPN revealed the resident could not walk on her own, but would scoot or crawl, but that's about it. Interview with the Director of Nursing (DON) on 12/7/16 at 10:40 AM in the resident's room confirmed the resident had no personal items, pictures or decor in her room and confirmed the dirty torn fall mat. When asked why the resident had nothing of interest to focus on in her room, the DON stated, We didn't anticipate her being on isolation this long. The DON confirmed staff had to stand over the resident when entering the room for all care, the resident was unable to move from the mattress on the floor without assistance, and crawled in the room. The DON confirmed the facility failed to provide an environment that enhanced the resident's respect and dignity.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to investigate the cause of fractures of unknown origin for 1 (Resident #1) and failed to investigate bruises of unknown origin for 1 (Resident #3) of 7 residents reviewed for abuse/neglect. The findings included: Review of a facility policy titled Abuse Prevention/Reporting Policy and Procedure undated revealed, .Signs of Potential Abuse .Bruising not consistent with specific resident .Unexplained fracture .Staff will be provided information regarding the process for reporting .suspected abuse to their immediate Supervisor, Abuse Coordinator, local authorities and State Department of Health .Facility management is required to accept all allegations of abuse and conduct a complete and thorough investigation including reporting to the proper authorities .All reports whether from family, residents or staff will be reported immediately to the Administrator and Abuse Coordinator and or/D.O.N. (Director of Nursing) .The Administrator and the D.O.N. will conduct a comprehensive investigation of any and ALL allegations of abuse .in accordance with state law, federal regulation and The Patient Protection and Affordable Care Act (Elder Justice Act) . Review of the facility policy entitled Falls - Clinical Protocol, revealed .8. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. 12. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined the cause cannot be found or that finding a cause would not change the outcome or management of falling and fall risk. 16. The staff with the physician's guidance, will followup on any fall with associated injury until the resident is stable and delayed complications such as late fractures or subdural hematoma have been ruled out or resolved . Review of the facility policy entitled Assessing Falls and Their Causes revealed .5. Nursing staff will observe for delayed complications of a fall approximately 48 hours after an observed or suspected fall, and will document findings in the medical records . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was severely impaired cognitively. Continued review of the MDS revealed Resident #1 required extensive assistance with transfers, dressing, eating, and grooming; was dependent for bathing; was always incontinent of bowel and bladder; and ambulated with supervision. Review of Incident Reports for 2016 revealed Resident #1 sustained falls on: 3/28/16 at 1:56 AM in the dining room where he had a skin tear. 4/11/16 at 7:30 PM in the dining room 4/15/16 at 6:21 PM in his room, sustaining a skin tear 5/2/16 at 10:35 AM in his room 5/3/16 at 4:35 PM in his room 5/12/16 at 3:00 PM in the dining room and sustaining a hematoma 5/28/16 at 3:45 PM in the hallway 6/2/16 at 3:00 PM in the dining room 6/3/16 at 3:00 PM in his room 6/13/16 at 7:15 AM in his room 6/15/16 at 7:51 AM in his room. Review of the investigation of the fall which occurred on 6/2/16 revealed the resident was in the dining room; noted something on the floor; reached to pick it up; and fell from the chair. Continued review revealed the resident did not sustain any injury. Further review of the investigation revealed the cause of the accident was clutter on the floor so those items were removed from the area. Medical record review of a Fall Risk Evaluation dated 5/22/16 revealed Resident #1 scored 21 indicating he was at risk for falls. Continued review of evaluations dated 6/2/16 and 6/3/16 revealed Resident #1 again received a score of 21. Review of the investigation of the fall which occurred on 6/3/16 revealed Resident #1 was found lying face down in another room beside Bed B and had sustained a laceration to the left side of the head measuring 2.2 centimeters. Continued review revealed the cause of the incident was .Resident becomes tired after being up for extended period of time, refused to rest . Further review of the incident revealed immediate intervention included placing Resident #1 in a wheelchair with alarm to provide supervised rest periods. Medical record review of nursing notes dated 6/5/16 revealed the nurse was called to the room by the Certified Nursing Aide (CNA) to look at the resident's hand. Continued review revealed the resident's left hand was blue and swollen from the wrist to the middle of the fingers. Further review revealed Resident #1 was transferred to the hospital for x-rays of the hand. Review of the Emergency Department (ED) record dated 6/5/16 revealed the resident .sustained another fall and he was found to have metacarpal (hand) fractures of the fingers 3, 4, and 5 on the left hand. Continued review revealed the resident had a soft splint on the left forearm and hand with an ace type wrap. Further review of the ED record revealed an x-ray of the resident's left hand which showed third through fifth obliquely (fracture at an angle) oriented metacarpal fractures. Continued review of the ED record revealed the physician's statement .Consult SS (Social Services) to eval (evaluate) incident report on injury to (L) (left) hand multiple suspicious fractures . Medical record review of the care plan revealed no mention of the [MEDICAL CONDITION]; the splint on his hand; observations to be made of the fingers; and care of the splint and the resident's hand. Continued review revealed the CNA care card did not address the fractured fingers, the splint, and observations to be made of the fingers. Review of Incident Reports revealed no report for the [MEDICAL CONDITION]'s left hand. Review of the SBAR (Situation, Background, Appearance, and Review) which serves as physician notification, revealed one SBAR for each fall the resident sustained [REDACTED]. Observation of Resident #1 on 6/22/16 at 9:40 AM revealed him lying on his back, asleep, mouth breathing with oxygen cannula in place. Continued observation revealed the resident's face was very red and he had a large (5 inches by 2 inches) dark brown bruise to the back of the hand and wrist of the right hand. Further observation revealed a splint to the left hand which was wrapped with an ace bandage. Continued observation revealed the fingers of the left hand were dark blue on the back and the fingers of both hands were bent at a 90 degree angle at the knuckles. Interview with the Director of Nursing (DON) on 6/21/16 at 10:45 AM in the Admissions Office revealed Resident #1 had frequent falls. Continued interview confirmed a separate investigation into the finger fractures was not done because the facility felt they knew the cause of the finger fractures - his fall the previous night. Interview with the DON and Administrator on 6/21/16 at 3:15 PM in the Administrator's office revealed Resident #1 fell on Thursday and Friday, 6/2/16 and 6/3/16. Continued interview revealed the fingers were noted to be blue on 6/5/16 and the assumption was made the fractures occurred with the fall on 6/3/16. Continued interview revealed the facility assumed the finger fractures were related to the fall on 6/3/16 with the position of the resident when found but the exact cause of the fractures was still unknown. Continued interview revealed the Administrator confirmed the fractures of the fingers of unknown origin were not investigated. Telephone interview with (Licensed Practical Nurse) LPN #1 on 6/22/16 at 10:20 AM revealed on 6/3/16 the lady in room [ROOM NUMBER] came to the nurses' station and said a man fell in her room. Continued interview revealed she went to the room and found Resident #1 lying on his left side with his left hand stretched toward the bathroom. Further interview revealed LPN #1 assessed the resident and he had full range of movement as well as the ability to squeeze her hands equally. Further interview revealed LPN #1 did not notice any issues with the resident's left hand and said he grasped using his thumb and forefinger due to the other 3 fingers being permanently bent. Continued interview revealed LPN #1 was asked by the nurse on 6/5/16 to look at the left hand of Resident #1 which she noted to be blue from the wrist to the knuckles. Further interview revealed the resident was sent out for an x-ray of the hand where the fractures were discovered. Continued interview revealed there was nothing in change of shift report on 6/4/16 about the resident's hand being bruised and swollen. Telephone interview with CNA #3 on 6/22/16 at 11:15 AM revealed Resident #1 fell on a Friday and she was the only CNA on the hall with a nurse. Continued interview revealed another resident told her and the nurse someone fell in her room. Further interview revealed the resident was lying between the bed and air conditioner and thinks he was face down with his left side by the air conditioner and his right side by the bed. Continued interview revealed she could see his head from the door. Further interview revealed she checked his head and found the laceration above his ear. Continued interview revealed the nurse assessed the resident and no other injuries were found. Continued interview revealed Resident #1 was independent with ambulation and did not use a wheelchair at the time of the incident. Interview with the DON on 6/22/16 at 2:55 PM in the Admissions Office confirmed the facility failed to investigate the cause of the finger fractures but assumed they occurred with the fall on 6/3/16. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of a 60 day MDS dated [DATE] revealed the resident had short and long term memory loss and was severely cognitively impaired. She had behaviors of pacing, wandering, and delusions. She was independently ambulatory with supervision. Medical record review of Nurse's Notes dated 3/18/16 at 7:00 PM documented, Area above (left) eyebrow noted to be bluish-(Resident) denied any trauma-earlier in the day (Resident) was seen laying head down on tables, etc. in dining room. Medical record review of a Customer First Concern/Grievance Report for Resident #3 dated 3/21/16 revealed, .Resident has black eye . The resolution was resolved on 3/21/16 and signed by the DON and the Administrator. Interview with the Social Worker (SW) on 6/21/16 at 4:00 PM in the SW's office confirmed she received a phone call from the resident's daughter on 3/21/16 regarding a black eye observed on 3/20/16 while visiting the resident. The SW stated LPN #3 had spoken with both daughters by phone and explained the resident was laying herself on the floor, and laid her head on tables, and was most likely the cause of the bruising. Interview with the Administrator and DON on 6/21/16 at 4:15 PM in the Administrator's office confirmed they were aware of Resident #3's black eye on 3/21/16 when the daughter called and spoke with the SW. The Administrator stated they had watched video's of the resident laying her head on tables and counters and that was most likely the cause of the bruise. The DON confirmed the facility failed to conduct an investigation for a bruise of unknown origin to the resident. The Administrator confirmed the facility failed to report a black eye for Resident #3 in accordance with state law, federal regulations and the Elder Justice Act.

Based on medical record review, facility investigation review, and interview, the facility failed to update the care plan to address care for and observations of a resident with fractured fingers for 1 (Resident #1) and failed to update the care plan to reflect interventions to prevent further bruising for 1 (Resident #3) of 7 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was severely impaired cognitively. Continued review of the MDS revealed Resident #1 required extensive assistance with transfers, dressing, eating, and grooming; was dependent for bathing; was always incontinent of bowel and bladder; and ambulated with supervision. Review of the investigation of the fall which occurred on 6/2/16 revealed the resident was in the dining room; noted something on the floor; reached to pick it up; and fell from the chair. Continued review revealed the resident did not sustain any injury. Further review of the investigation revealed the cause of the accident was clutter on the floor so those items were removed from the area. Review of the investigation of the fall which occurred on 6/3/16 revealed Resident #1 was found lying face down on another room beside Bed B and had sustained a laceration to the left side of the head measuring 2.2 centimeters. Continued review revealed the cause of the incident was .Resident becomes tired after being up for extended period of time, refused to rest . Further review of the incident revealed immediate intervention included placing Resident #1 in a wheelchair with alarm to provide supervised rest periods. Medical record review of nursing notes dated 6/5/16 revealed the nurse was called to the room by the Certified Nursing Aide (CNA) to look at the resident's hand. Continued review revealed the resident's left hand was blue and swollen from the wrist to the middle of the fingers. Further review revealed Resident #1 was transferred to the hospital for x-rays of the hand. Review of the Emergency Department (ED) record dated 6/5/16 revealed the resident .sustained another fall and he was found to have metacarpal (hand) fractures of the fingers 3, 4, and 5 on the left hand. Continued review revealed the resident had a soft splint on the left forearm and hand with an ace type wrap. Further review of the ED record revealed an x-ray of the resident's left hand which showed third through fifth obliquely oriented metacarpal fractures. Continued review of the ED record revealed the physician's statement .Consult SS (Social Services) to eval (evaluate) incident report on injury to (L) (left) hand multiple suspicious fractures . Medical record review of the care plan revealed interventions were listed for each fall Resident #1 had sustained. Continued review of the care plan revealed no mention of the [MEDICAL CONDITION]; the splint on his hand; observations to be made of the fingers; and care of the splint and resident's hand. Observation of Resident #1 on 6/22/16 at 9:40 AM revealed him lying on his back, asleep, mouth breathing with oxygen cannula in place. Continued observation revealed the resident's face was very red and he had a large (5 inches by 2 inches) dark brown bruise to the back of the hand and wrist of the right hand. Further observation revealed a splint to the left hand which was wrapped with an ace bandage. Continued observation revealed the fingers of the left hand were dark blue on the back and the fingers of both hands were bent at a 90 degree angle at the knuckles. Interview with the DON on 6/22/16 at 2:55 PM in the Admissions Office confirmed the care plan for Resident #1 did not address the [MEDICAL CONDITION] to include observations to be made of the splint; care of the skin under the splint; and observations of the fingers. Continued interview confirmed the CNA care card did not include the fractures of the fingers including observations to be made of the splint and fingers as well as when to notify the nurse. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of a 60 day Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory loss and was severely cognitively impaired. She had behaviors of pacing, wandering, and delusions. She was independently ambulatory with supervision. Medical record review of a comprehensive care plan dated 3/21/16 revealed no problem of a left black eye identified on 4/17/16, or bruises identified to the resident's right shoulder, below the left and right breast or the left inner thigh identified on 5/12/16. Continued review revealed the care plan was not updated to reflect problems of injury related to lying the head on the table or counter, leaning on walls, or use of Aspirin. The comprehensive care plan included an undated problem of signs and symptoms of [DIAGNOSES REDACTED] (sleep disorder that causes overwhelming daytime drowsiness) with no approaches included. Interview with the Director of Nursing (DON) on 6/21/16 at 10:00 AM in the Admissions office confirmed the comprehensive care plan did not reflect Resident #3's problem of bruising when identified on 4/17/16 and 5/12/16, nor provide approaches for a problem of [DIAGNOSES REDACTED]. Continued interview with the DON confirmed the facility failed to prevent future bruising to the resident by not updating the care plan with approaches to protect the resident after behaviors of stumbling into walls, leaning over the gate at the nurse station, laying her head on tables or counters, or hitting her leg on the leg of tables was identified by the facility.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to follow its policy on fall assessment and failed to follow accepted standards of practice for 1 (Resident #2) of 7 residents reviewed. This failure had the potential to cause harm to the resident. The findings included: Review of the facility policy entitled Assessing Falls and Their Causes, revised 10/10, revealed: 1. If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. 2. If there is evidence of a significant injury such as fracture or bleeding, nursing staff will provide appropriate first aid. 3. Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was severely impaired cognitively. Continued review of the MDS revealed Resident #2 required extensive assist of two people with transfers, dressing, and grooming; was dependent on one person for bathing; required extensive assist of one person for eating; and was always incontinent of bowel and bladder. Further review of the MDS revealed Resident #2 exhibited behaviors of screaming at others and wandering. Medical record review of nurses' notes dated 3/20/16 at 1:05 AM, revealed .Resident noted to be on floor on rt (right) side of bed on rt (right) side. Upon assessment wide area of discoloration to anterior of hip. c/o (complaining of) severe leg and hip pain. MD (physician) notified and ordered to send to ER (emergency room ) to eval (evaluate) and tx (treat). Resident left facility at 1:25 AM via ambulance service . Review of the History and Physical from the hospital dated 3/20/16 revealed x-ray of the right hip showed a .right subcapital (under the head of the femur) femoral neck fracture which will be surgically repaired Monday morning . Continued review of hospital documents revealed Resident #2 required a blood transfusion and had the hip surgically repaired before returning to the facility on [DATE]. Interview with the Director of Nursing (DON) on 6/20/16 at 2:40 PM in the Admissions Office revealed the CNAs found Resident #2 on her knees with her torso on the bed in another resident's room (#139). Continued interview revealed the CNAs stood resident up and placed Resident #2 in a wheelchair; took her to her own room; stood her up and attempted to ambulate her when she hollered in pain and was unable to weight bear. Interview with the Administrator on 6/21/16 at 3:15 PM in the Administrator's office, stated Resident #2 fell to her knees and broke her hip. Continued interview revealed the femur head was broken off but there was no definitive root cause analysis. In further interview the Administrator stated the hip could have been cracked and the head snapped with movement to the chair and/or bed. Telephone interview with CNA #1 on 6/21/16 at 9:35 AM, revealed she and another CNA found Resident #2 in another resident's room (#139) kneeling on the floor with the rest of her body on the bed. Continued interview revealed Resident #2 often laid across the ends of beds. Further interview revealed they helped the resident to the wheelchair and put her in bed in her own room then got the nurse to come and look at her. Telephone interview with CNA #2 on 6/21/16 at 9:50 AM, revealed Resident #2 was in another room (#139) kneeling on the floor. Continued interview revealed CNA #1 and CNA #2 got her up and took her to her room then went to get the nurse. Further interview revealed they could see she was in a lot of pain so they lifted her into the chair and then into bed. Telephone interview with LPN #2 on 6/22/16 at 12:40 PM revealed she was called on her cell phone because the CNA wanted her in the room of Resident #2. Continued interview revealed when she arrived the resident was in bed and in obvious pain so she assessed the resident and determined she needed to go to the ER. Further interview revealed the CNA stated Resident #2 must have rolled out of bed. Continued interview revealed a few days later LPN #2 was called by the DON who stated they had watched the video and saw the CNAs push Resident #2 from room [ROOM NUMBER] down the hall across the dining room and into her room in a wheelchair. Further interview revealed the CNAs tried to get Resident #2 to ambulate to her room and did not realize she was hurt. Continued interview revealed when they got to the resident's room they put her to bed. Further interview revealed at the time of the incident Resident #2 was independent with ambulation. Continued interview revealed the last time she cared for Resident #2 the resident was dependent with transfers and wheel chair bound. Review of the Monthly Summary dated 3/1/16 prior to the fall, revealed Resident #2 had unclear speech and was sometimes understood so she was considered to be severely impaired cognitively. Continued review revealed Resident #2 required limited assistance with transfers; required extensive assistance with dressing, eating, toileting, and grooming; was total dependence with bathing; was always incontinent of bowel and bladder. Review of the Monthly Summary dated 5/18/16 after the fall, revealed Resident #2 revealed the resident had clear speech and was understood but had memory problems so was considered to be moderately impaired cognitively. Continued review of the summary revealed Resident #2 was total dependence for transfers, dressing, eating, toileting, bathing, and grooming; used a wheelchair; had a foley catheter in place; and was always incontinent of bowel. Review of the facility investigation dated 3/20/16 revealed Resident #2 was found by Certified Nursing Aides (CNAs) in another room with her knees on the floor and her torso on the bed. Continued review revealed the resident was unable to weight bear and had a large area of bruising on her anterior right hip. Continued review revealed the nurse documented Resident #2 rolled out of bed onto the floor and the CNAs put the resident into bed before the nurse arrived. Further review revealed no one knew how the fracture occurred. Continued review revealed the camera system was checked and showed the CNAs taking Resident #2 in a wheelchair from another room into her own room. Further review revealed the statements of the CNAs did not match the video tapes Interview with the DON on 6/22/16 at 2:30 PM in the Admissions Office confirmed Resident #2 should not have been moved by the CNAs before she was assessed by the nurse per facility policy and recognized standards of resident care. This caused potential harm to Resident #2.