Every finding on record at Eunice Manor

Facility failed to post current staffing information Findings:Review of the facility's policy, Posting of Staffing, with a last review date of 01/12/2026 revealed the following in part, Purpose: To visibly see facility staffing levels that comply with federal and state requirements. Policy: Post daily staffing information daily in a prominent, easily accessible, and visible area for residents and visitors.On 01/11/2026 at 8:30 a.m., upon entrance to the facility, the Daily Staffing Report was observed posted on a glass window of an office located near the front entrance of the facility. The report was dated for 01/06/2026. On 01/12/2026 at 1:37 p.m., an interview was conducted with S2DON (Director of Nursing). She confirmed that the staffing information posted on 01/11/2026 at 8:30 a.m., near the front entrance of the facility, was dated for 01/06/2026. She further confirmed the posted staffing information was outdated, and should have been current with staffing information for 01/11/2026.

Based on observations, interviews, and policy and procedure reviews, the facility failed to: 1. Maintain a clean and sanitary kitchen to prevent cross contamination and the likelihood of foodborne illnesses and 2. Store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 79 residents who consumed food from the kitchen. Findings: Review of the facility's policy, Sanitization, with a last review date of 01/02/2026, revealed the following in part: Policy Statement: The food service area is maintained in a clean and sanitary manner. 1. All kitchen, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. Review of the facility's policy, Refrigerators and Freezers, with a last review date of 01/02/2026, revealed the following in part: Policy Statement: The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41 degrees Fahrenheit and freezers keep frozen foods frozen solid. 2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures. 3. Monthly tracking sheets include time, refrigerator temperature, temperature of potentially hazardous foods (PHF)/time/temperature control for safety (TCS) food, initials, and action taken. The last column will be completed only if temperatures are not acceptable. 7. All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened. 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. An initial tour of the kitchen and interview was conducted with S1DM (Dietary Manager) on 01/11/2026 from 08:42 a.m. 9:30 a.m. S1DM observed and confirmed the cleanliness and food storage issues that included the following: 1. Dried white food particles and drip spots were observed on the stainless steel wall next to the steam table. 2. A three tiered rolling cart containing clean dishes and trays was observed with crumbs noted on all three shelves including yellow food crumbs noted in recessed areas of the top shelf. Yellow, dried, food debris was observed on the middle shelf. [NAME] and yellow dried food debris was observed on the bottom shelf. 3. A steam table was observed with dried black, white, and yellow residue noted in the back corners of the bottom shelf. A dried, round, brown liquid stain, crumb debris, dust, and small pieces of paper were also noted to the bottom shelf of the steam table. 4. A shelf containing clean stock pots was observed with white, dried, food debris. 5. The bottom, front panel of the stove was observed with thick, dried, yellow residue and food debris. 6. Dried food debris and trash debris was observed on the floor behind a prep table near the walk in cooler. 7. Dried white, yellow, and brown food debris along with a brown, dried, drip stain was observed in the bottom storage of a prep table. 8. A reach in cooler was observed sitting on a counter containing one pitcher of lemonade, one pitcher of pink lemonade, six small containers of orange juice, twelve small containers of apple juice, and ten small containers of cranberry cocktail. S1DM stated that there was no temperature monitoring for this refrigerator at the time of observation. 9. A box containing four packs of sliced turkey breast was observed in the walk in cooler with Use by or freeze by 12/15/2025 printed on the box. S1DM confirmed that the box of sliced turkey breast was expired and should have been discarded at the time of observation. 10. A double pack of ground meat was observed in the walk in freezer. The ground meat was in plastic wrapping without any indication of the date the item was received. S1DM stated that the ground meat had been removed from the box it was received in, and confirmed that the date the item was received should have been labeled on the packs of ground meat.

Based on observations and interview, the facility failed to maintain a safe, sanitary environment as evidenced by failing to ensure cookware was stored in a sanitary manner. This deficient practice had the potential to affect a total of 80 residents who consumed meals from the kitchen. On 12/02/2024 at 8:45 a.m., an observation was made of one sheet pan on the floor, in-between the fryer and the standing oven. On 12/02/2024 at 09:55 a.m., a second observation was made of a sheet pan on the floor, in-between the fryer and the standing oven. An immediate interview was conducted with S4RD (Registered Dietician), she confirmed the sheet pan was on the floor and it should not have been.

Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of facility-initiated transfer for 1 (Resident #57) out of 2 (#22, #57) residents investigated for hospitalization . The deficient practice has the potential to affect a census of 81. Findings: A request was made for the facility's policy for Ombudsman notifications of hospital transfers to S1ADM (Administrator). No policy was provided by the time of exit. Review of Resident #57's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that read in part, Spastic Hemiplegia Affecting Left Nondominant Side, Lobar Pneumonia, Unspecified Organism, Sepsis, Unspecified and Other Seizures. Review of Resident #57's nurses' notes revealed on 08/14/2024 at 12:21 p.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 08/15/2024 at 12:35 p.m., the resident returned from the hospital back to the facility. Review of the Emergency Transfer Log for August 2024 revealed Resident #57's transfer to the hospital on 08/14/2024 was not identified on the list. On 12/04/2024 at 1:19 p.m., an interview and record review was conducted with S3BOM (Business Office Manager). She confirmed she was responsible for the Emergency Transfer Log and to send it to the State Long Term Care Ombudsman. S3BOM reviewed Resident #57's EMR (Electronic Medical Record) and confirmed the resident was transferred to the hospital on 08/14/2024. She then reviewed the Emergency Transfer Log for August 2024 and confirmed the resident was not listed as having been transferred on that date. S3BOM confirmed that Resident #57 should have been listed on the Emergency Transfer Log sent to the State Long Term Care Ombudsman and was not. S1ADM was present during the interview and also confirmed that Resident #57 was not included on the Emergency Transfer Log sent to the State Long Term Care Ombudsman and should have been.

Based on observation and interview, the facility failed to ensure: 1. the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors, and 2. the daily nurse staffing information include the total number and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. Findings: On 12/03/2024 at 3:30 p.m., an observation was made of the daily nursing staffing information posted next to the staff time clock near the dining room and nurse's station which are in the central area of the building. The posting did not include the total number and actual hours worked by the staff responsible for resident care. On 12/03/2024 at 3:45 p.m., an observation and interview was conducted with S1ADM (Administrator) and S2RN (Registered Nurse). An observation of the nursing staffing information posted near the staff time clock was conducted with S1ADM and S2RN. They both confirmed that the posting did not include the total number and actual hours worked by the staff responsible for resident care. When asked if the posting was readily accessible for residents and visitors, S2RN did agree not all residents or visitors went to the dining room and may not see the posting. S1ADM voiced that she had always posted the nursing staffing information this way and posted it by the staff time clock. She stated that she was unaware that the nursing staffing information needed to include the total number and actual hours worked by the staff.

Based on record review and interview, the facility failed to ensure a discharge MDS (Minimum Data Set) assessment was completed timely for 1 (Resident #56 ) out of 39 sampled residents. The deficient practice had a potential to affect a total census of 77. Findings: A review of Resident #56's electronic medical record revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 07/31/2023. Further review of Resident #56's electronic medical record revealed that no discharge assessment had been initiated. On 11/15/2023 at 9:37 a.m., an interview and record review was conducted with S1MDS. After review of Resident #56's electronic medical record, she confirmed that the discharge MDS assessment for the resident's discharge on 07/31/2023 was never completed and was overdue.

Based on review of records and interviews, the facility failed to ensure each resident was free from misappropriation of resident property and exploitation. This was evidenced by 3 (#2, #3 and #4) of 5 ( #1-#5) sampled residents who experienced misappropriation of property/finances while residing in the facility with a census of 78 residents. Findings: Review of the facility's policy and procedure for Abuse Investigation and Reporting revealed the Components of Abuse consisted of screening, training, preventing, identifying, reporting and knowing the different types of abuse such as financial exploitation. Resident #2. Resident #2's record review revealed the resident was an [AGE] year old resident with an admitted [DATE]. The Resident had a BIMS (Brief Interview for Mental Status score) of 12. A score of 0 -7 = severely impaired cognition, 8 - 12 = moderately impaired and 13 - 15 represented intact cognition. During an interview with Resident #2 on 02/10/2022 at 1:50 PM, Resident #2 informed of an incident where her bank credit card went missing from her purse from within her room. She said she kept her credit card in her purse with her in her room at all times. She said whoever took her card, took it without her permission from her purse. She said the credit card was used without her permission and she advised to question her responsible party (RP) for any additional information needed. A phone interview with Resident #2's RP on 02/10/2022 at 4:00 PM revealed Resident #2's credit card was taken from her purse, from her room in the facility and unauthorized charges of $18,000.00 plus was charged on the Resident's credit card. The RP said she was notified of the unauthorized charges on the card when the Resident's bank called to alert them of out of the ordinary transactions on the credit card. She said this occurred around the Christmas holiday in 2021. The RP said she called the Resident and questioned about having a credit card at the facility. Resident #2 said she did have a credit card with her at the facility and looked for it at that time, but the card was not in her purse where she kept it. Resident #2's said she called the facility administrator after speaking with Resident #2 and the administrator did not have the Resident's credit card or knowledge of the resident having a credit card in the facility. The RP said she called the bank, got the bank statement and 3 days after discovering the card was missing, The RP reported to the authorities. Resident #2's RP said by the time she went to the authorities, she and the administrator of the facility had obtained information of video surveillance at a local [NAME] where the card was used without authorization. The RP said they got a description of the vehicle used by the person making the unauthorized purchase and gave that information to the authorities. The RP said the investigating officer had video and audio recordings of the nursing home employee who used Resident #2's credit card making unauthorized purchases. The RP said the bank reimbursed $18,000 Plus for unauthorized purchases made with the stolen card and a nursing home employee was arrested and charged with the crime of stealing and using Resident #2's credit card without permission. A phone interview conducted with law enforcement deputy on 02/10/2022 at 4:15 PM verified that Case ####### was investigated and S2CNA was arrested for charges consisting of: 259 counts of fraud for using the stolen credit card belonging to Resident #2, 16 counts of identity theft for calls to the victims Credit Card Company to payout the balance of the stolen card and 4 counts of contributing to the delinquency of a minor. The deputy said the accused was arrested 01/31/2022 on the above charges. Resident #3. Resident #3's record revealed she was [AGE] years old and admitted to the facility on [DATE]. She had a BIMS score of 07. Review of a Concern Form dated 11/22/2021 for Resident #3 revealed the resident reported her bank card was missing. The investigation part of the form documented the resident had previously misplaced the card several times, the RP was informed and the card was canceled. Additional entry dated 11/23/2021 revealed the RP provided transactions made with Resident #3's card that were not believed to have been purchases made by the resident. One purchase was made at a service station in a different city from where the resident/nursing home was located. The follow-up section of the form documented by S1Administrator (Adm) revealed the Resident's RP did not want to press charges because it was not worth the trouble. Additional record review revealed an incident, dated 11/23/21, documented by S1Adm. Resident #3's RP informed that the Resident's bank card was used on multiple occasions for various purchases totaling $137.00. S1Adm documented an internal investigation was ongoing with staff interviews and the Resident's bank had refunded the charges and canceled the card. During an interview with Resident #3 on 2/11/2022 at 11:00 AM, Resident #3 said she has never filed a grievance or complaint, but had an I-pad and a debit card went missing from her room in the nursing home. She explained that her debit card was in her purse in her closet when it went missing around 3 months ago. She said she told S1Adm about her debit card when she discovered it was not in her purse. I went to look for my debit card to use it one day and it was not in my purse. She said her nephew worked at the bank and he managed that for her. During a phone interview with Resident #3's RP on 02/11/2022 at 1:30 PM, the RP verified he oversaw Resident #3's bank card and said it was used at 3 or 4 locations that he knew was not charges made by Resident #3. He said he reported the unauthorized card use to S1Adm. He said S1Adm wanted him to press charges, but the unauthorized card charges totaled about $140.00 and he was not going to make a police report for $140.00. He said the charges included a retail store and a gas/service station in a surrounding city. Resident #3's RP said the money was reimbursed by the bank. Resident #4. Resident #4's record revealed he was [AGE] years old, admitted to the facility 08/01/2021 and had a BIMS score of 06. Review of a Concern Form dated 11/23/2021 revealed he voiced a concern that $50.00 was missing from his wallet he had in his hanging pants. Resolution: 11/29/2021 = Money had not been found. S1Adm phoned RP and will replace $50.00 into his personal account. A receipt for $50.00 dated 11/29/2021, for - Reimbursement, was attached to the concern along with staff questionnaires, in-services and staff signature sheets on abuse/neglect and theft. Resident #4 was interviewed on 02/10/2022 at 12:55 PM. Resident #4 said he did tell a staff member about money that was missing from his wallet. He said he had $57.00 in his wallet consisting of bills/denominations of 20's, 10's, 5's and 1's. He said the only instance he could think of was his money went missing while his wallet was in his pants outside a shower stall while he was in the shower room. He said about 3 days after showering, he opened his wallet and discovered his money was missing. A phone interview with Resident #4's RP, on 02/11/2022 at 1:37 PM, revealed her father had $50.00 taken from his wallet while in the nursing home. She explained that her mother visited her father every two or three days and she gave him another twenty-dollar bill before his money went missing, so he had $50.00 in his wallet when the money went missing. Resident #4's RP said S1Adm called her and informed of her father's report of the missing money. She said S1Adm did an investigation, but the money was never found so the nursing home reimbursed the $50.00 to his facility-managed account. During interview and review of records with S1Adm on 02/14/2022 at 11:15 AM, S1Adm said Residents #2, #3, and #4 and/or RPs had reported issues involving missing money and unauthorized charges on money access cards. S1Adm said despite investigations and ongoing in-service training of staff, one (Resident #2's) of the three (Residents #2, #3 and #4) reported incidents were able to be substantiated and that one substantiated case resulted in an arrest of a nursing home employee.

Based on observation, interview and record review, the facility failed to ensure that foods were stored in accordance with professional standards for food service safety by failing to ensure that 2 of 3 refrigerators in the kitchen maintained safe temperatures and by storing a hand scoop buried in flour inside of a bulk storage container. This had the potential to affect 107 of the residents that consumed foods from the kitchen out of a total census of 107. FINDINGS: An observation was made on 10/22/18 at 9:46 a.m. of a hand scoop buried inside of the flour bulk storage bin. An interview as conducted with S3KS on 10/22/18 at 9:47 a.m. and she confirmed that the scoop was buried with the handle in the flour of the bulk container. She stated the scoop handle should not have been buried in the flour. An observation was made on 10/22/18 at 9:58 a.m. of 2 reach in refrigerators with multiple glasses of milk in one and boxed milk in the other. Further observation failed to reveal temperature logs kept for these refrigerators. An interview as conducted with S3KS on 10/22/18 at 9:59 a.m. and she confirmed that there were no temperature logs kept on these 2 refrigerators. At this time, she stated that she was in charge since the acting dietary manager left and that she had not seen to it that the temperature logs were kept on these 2 refrigerators. She pointed out that she planned to replace the logs but had not done so yet. An interview was conducted with S4Cook on 10/25/18 at 2:25 p.m. and she confirmed that she was present on 10/22/18 at 9:58 a.m. when the temperature logs were requested for the 2 reach in refrigerators. She confirmed there were no logs present and that the staff had not been documenting the temperatures on these 2 refrigerators. She added that the last dietary manager left approximately 1 month ago and the temperature logs for these 2 refrigerators had not been replaced since she left.

Based on observation, interview, and policy review, the facility failed to ensure that the resident environment remains as free from accident hazards as possible as evidenced by the hot water temperatures exceeding the maximum acceptable temperature of 120 degrees for 16 (#2, 3, 4, 15, 22, 23, 25, 33, 53, 70, 77, 87, 92, 102, 125, and 130) of 39 stage 2 sampled residents whose hot water temperatures were measured, of a total census of 119 residents. FINDINGS: On 10/30/17 at 2:00 p.m., an interview was conducted with S3Maintenance. He stated that the hot water is supposed to be kept at a maximum of 120 degrees. Between 2:00 and 2:30 p.m., the hot water temperatures were assessed with [REDACTED]. In the shared bathroom for Resident #23 and #15, the hot water temperature was 138 degrees; in the shared bathroom for Resident #87 and #130, the hot water temperature was 136 degrees; in the shared bathroom for Resident #4 and #2, the hot water temperature was 137 degrees; in the shared bathroom for Resident #53 and #70, the hot water temperature was 136 degrees; in the bathroom for Resident #25, the hot water temperature was 136 degrees; in the shared bathroom for Resident #33 and #22, the hot water temperature was 139 degrees; in the shared bathroom for Resident #125 and #3, the hot water temperature was 137 degrees; in the bathroom for Resident #92 the hot water temperature was 140 degrees; in the bathroom for Resident #102, the hot water temperature was 136 degrees. S3Maintenance confirmed that the temperatures were all above the maximum hot water temperature of 120 degrees. On 10/30/17 at 2:36 p.m., the hot water temperature in Resident #35s bathroom was tested by S1ADM. She confirmed it was 132degrees. S1ADM confirmed that the hot water temperature was not to exceed 120 degrees. On 10/30/17 at 3:48 p.m., the hot water temperature in Resident #77's bathroom was tested by S1ADM. She confirmed it was 126 degrees. A review of the facility's policy for water temperatures provided by S1ADM was conducted. The policy included that the hot water supply to the hand washing and bathing faucets in the resident areas should not be more than 120 F (Fahrenheit) at the faucet outlet.

Based on record review and interview, the facility failed to ensure each resident's drug regimen is free from unnecessary drugs by failing to monitor [MEDICAL CONDITION] for a resident taking two diuretics, [MEDICATION NAME] and [MEDICATION NAME], for 1(#9) of 5 (#9, #17, #52, #53, #72) residents reviewed for unnecessary medications during Stage 2 of the survey. This deficient practice had the potential to affect a total census of 119 residents. Findings: Record review revealed Resident #9 was a [AGE] year old female with the following Diagnoses: [REDACTED]. Record review revealed a physician's orders [REDACTED]. On 8/31/17, the [MEDICATION NAME] dosage was increased to 40 mg by mouth one time a day. Record review revealed a physician's orders [REDACTED]. Record review of Resident #9's Medication Administration Record [REDACTED]. Record review of Resident #9's Nurse's Notes from April 2017-October 2017 failed to reveal documentation of the monitoring for [MEDICAL CONDITION]. A record review and interview was conducted on 11/2/17 at 10:50 a.m. with S1ADM. She reviewed the resident's April 2017-October 2017 MARs and confirmed there was no documentation that the nurses were monitoring for [MEDICAL CONDITION]. A record review and interview was conducted on 11/2/17 at 10:55 a.m. with S1ADM and S2DON. They reviewed the resident's April 2017-October 2017 Nurse's Notes and confirmed there was no documentation that the nurses were monitoring for [MEDICAL CONDITION]. During an interview on 11/2/17 at 11:05 a.m. with S1ADM, she confirmed that the nurses were not monitoring and assessing Resident #9 for [MEDICAL CONDITION] as required.

Based on observation, interview, and policy review, the facility failed to ensure the correct storage and disposition of biologicals by failing to dispose of medications that were discontinued and expired for 2 (#110 and #18) residents out of a total of 39 Stage 2 sample residents, of a total census of 119 residents. FINDINGS: On 11/02/17 at 11:10 a.m., an observation was conducted of medication storage area on Hall A. A medication storage bin for Resident #110 contained a box of Ipratropium 0.5mg (milligram) and Albuterol Sulfate 3 mg aerosol treatment ampules with an expiration date on the box of 10/10/17. A medication storage bin for Resident #18 contained a box of Ipratropium Bromide 0.5mg and Albuterol Sulfate 3 mg aerosol treatment ampules with an expiration date on the box of 10/10/2017. A concurrent interview was conducted with S4LPN, and she confirmed that the medications were expired. She stated that expired medications are to be taken out of the residents' medication bins and placed in an expired medication bin. On 11/02/2107 at 11:30 a.m., an interview and record review was conducted with S5LPN. She stated that the orders for Ipratropium 0.5mg and Albuterol Sulfate 3mg for both Residents #110 and #18 were discontinued by the physician. She provided a physician report which revealed that Resident #110's aerosol treatments had been discontinued on 7/17/17. She also provided documentation that Resident #18's aerosol treatments had been discontinued on 6/16/17. On 11/02/2017 at 1135, an interview conducted with S1ADM. She provided the facility's Discontinued Medication policy which included that discontinued medications will be put in a designated area in the medicine room until processing occurs. She confirmed that expired medications do not belong in the residents' bins, they belong in the discontinued bin.

Based on record review and interview, the facility failed to ensure that each resident's drug regimen is free of unnecessary medications by failing to have a rationale for denying a Gradual Dose Reduction of [MEDICATION NAME] for 1 (#20 ) of 5 (#20, #131, #23, #57, #29) residents reviewed for medication use. Findings: Resident #20 was admitted [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#20 was placed on [MEDICATION NAME] 40 mg (milligrams) once daily on 3/26/14. Further review of the orders revealed that the dose was not decreased since admission. The form titled Request for Gradual Dose Reduction (GDR), addressed to S2MD, dated 1/25/16, from S3Pharmacist, had a recommendation to reduce the [MEDICATION NAME] 40 mg. The response from the doctor was to not taper the drug. Further review revealed no rationale for denying the GDR request. Another Request for Gradual Dose Reduction (GDR), addressed to S2MD, dated 10/25/16, from S3Pharmacist, had a recommendation to reduce the [MEDICATION NAME] 40 mg. The response from the doctor was to not taper the drug. Further review revealed no rationale for denying the GDR request. A review of the progress notes by S2MD from January - December 2016 revealed no information regarding the [MEDICATION NAME] or the reason that the GDR requests were denied. During an interview with S4LPN on 12/15/16 at 9:00 a.m., she stated that she cared for Resident #20. She stated he has not had any signs of depression since she began working with him over a year ago. She stated that S2MD never decreased his antidepressant medication, but did not know why. During an interview with S1DON on 12/14/16 at 3:40 p.m., she reviewed Resident #20's GDRs, physician's progress notes and clinical record. She verified that there were no documented rationales by Resident #20's physician for the GDR denials for [MEDICATION NAME].

Based on record review and interview the facility failed to follow physician's orders by allowing a resident to exceed her fluid intake as ordered by her physician for 1 of 1 residents receiving [MEDICAL TREATMENT]. #84 Findings: On 12/15/16 the resident's physician's orders were reviewed. The orders stated, restrict the residents fluids to 1 liter every 24 hours. At that time a review of the resident's intake ond output record was reviewed. It revealed the resident had exceeded her allowance of fluid on the following days: 12/6/16 1080ml (milliliters) 12/7/16 1080ml 12/10/16 1340ml 12/11/16 1580ml 12/12/16 1380ml 12/13/16 1450ml 12/14/16 1560ml On 12/15/16 at11:30 AM, S1DON was interviewed. She stated there should be totals for each 24 hours to ensure the resident does not go over 1000 cc's per 24 hour period

Based on record review and interview the facility failed to maintian complete and accurate records by not completing intake and output records for 1 of 1 resident on [MEDICAL TREATMENT]. (Resident #84) Findings: On 12/15/16 the resident's Intake and Output record was reviewed. It revealed the following dates did not have the amounts of fluid intake for the shift and/or the 24 total for the resident for the following dates and times between 12/1/16 and 12/7/16: 24 hour total on 12/1/16 3-11 shift and 24 hour total on 12/2/16 7-3 shift and 24 hour total on 12/3/16 24 hour total on 12/4/16 11-7 shift and 7-3 shift along with 24 hour total 24 hour total on 12/6/16 24 hour total on 12/7/16 On 12/15/16 S1DON confirmed there should have been totals for each shift and the 24 hour total.

Based on record review and interview the facility failed to carry out an unannounced emergency preparedness drill for an evacuation. This was evidenced by the facility did not have an evacuation drill for 2015. This had the potential to affect 122 residents in the facility that was documented on the Resident census and conditions of residents dated 10-26-15. Findings: Record review of the facilities emergency preparedness plan revealed there was no documentation in the Emergency Preparedness Binder that the facility had activated their evacuation plan in 2015. On 10-29-15 at 10:00 AM an interview with S11ADM revealed she did not activate the evacuation plan for 2015.

Based on record review and interview, the facility failed to ensure that the resident's comprehensive care plan was updated and revised by failing to document that the resident had become totally dependent on facility staff for eating, after returning to the facility from a hospitalization for 1 (#84) of 3 (#71, #84, and #120) residents reviewed for weight loss, out of a total of 64 stage 2 sampled residents. FINDINGS: A review of Resident #84 ' s electronic record revealed Nurses Notes dated 4/11/2015 at 9:51PM that Resident #84 fed herself. A review of Nurse ' s Notes dated 4/21/2015 starting at 4:55PM, revealed that the resident had choked during supper and had been transferred per physician's order [REDACTED]. Further review revealed the resident returned to the facility on [DATE]. A review of Resident #84 ' s care plans revealed one dated 6/9/15, and the most current, dated 7/20/15. Both care plans stated that the resident was able to feed herself with tray setup and supervision only. Review of an MDS (Minimum Data Set) assessment dated [DATE] revealed that Resident #84 was assessed as being totally dependent on one staff person for eating. A review of Dietary notes dated 7/16/15 revealed Resident #84 Is fed by staff and required total assistance with eating. On 10/28/15 at 10:00 AM, an interview was conducted with S18LPN. She stated that Resident #84 required total assistance with eating when she returned from a hospital stay in May 2015. On 10/28/15 at 10:05AM, an interview was conducted with S19CNA. She stated that she often assisted Resident #84 while she was here in the facility, and that prior to being hospitalized in April, she was independent and could feed herself. S19CNA stated that when the resident came back to the facility in May she could not feed herself at all, and was totally dependent on staff for eating. On 10/28/15 at 12:30 PM, an interview was conducted with S17DM. He stated that Resident #84 was hospitalized from [DATE] through 5/26/15, and when she returned to the facility, she required total assistance from staff with eating. On 10/29/15 at 10:30AM, S1DON reviewed a printed version of Resident #84 ' s current care plan and confirmed that it revealed that the resident was able to feed herself and required tray set up and supervision only. S1DON stated that the resident came back from hospital at end of May and was dependent on facility staff for eating and not independent or able to feed herself. She further stated that she will check with the care planning staff to see if there was a revision that was not on the printed care plan. On 10/29/15 at 11:00AM, an interview was conducted with S16MDS. She presented two care plans for Resident #84 that she had just printed. One had a handwritten date of 6/9/15 on it, and the other had a handwritten date of 7/20/15. She stated that she had conducted the assessments on the resident for the care plans dated 6/9/15 and 7/20/15. S16MDS reviewed the care plans and confirmed that both reflected that Resident #84 was able to feed self and needed tray set up and supervision only with eating. S16MDS stated that the resident had been hospitalized and returned to the facility on [DATE], and that she had assessed that the resident was totally dependent on staff for eating. S16MDS confirmed that she should have revised the care plan to reflect that Resident #84 was dependent on staff for eating and she had failed to do so.

Based on observations, record reviews, and interviews, the facility failed to formulate an advanced directive for 1 (#85) of 20 (#9, #18, #19, #23, #33, #47, #51, #52, #64, #69, #76, #85, #90, #99, #115, #118, #131, #135) residents reviewed for change of code status upon readmission to the facility after a hospitalization . The facility further failed to clarify a discrepancy between documentation on 1 ( #19) of 20 (#9, #18, #19, #23, #33, #47, #51, #52, #64, #69, #76, #85, #87, #90, #96, #99, #115, #118, #131, #135) residents advanced directive dated [DATE] and documentation during a hospitalization on physician progress notes [REDACTED]. Findings: Resident #85: Review of the facility's policy regarding Advanced Directives revealed the following: Policy Statement: Our facility will ensure that a resident's choice concerning the development of advance directives related to his/her refusal of medical or surgical treatment are followed in accordance with our facility's advance directive policies and procedures and current state law. Policy Interpretation and Implementation 1. Prior to, or upon admission, a representative of the social service department will provide residents with written information concerning the resident's right under state law to accept or refuse medical or surgical treatment and the resident's right to prepare an advance directive. Such information will include a written description of our facility's policies to implement advance directives and applicable state law. 2. Prior to or upon admission, the resident assessment coordinator will ask the resident and/or his/her family members about the existence of any advance directives prepared by the family. 3. A copy of the advance directive will be included in the resident's medical record located at the nurses' station. 4. Advance directives are defined as preferences regarding treatment options and include, but are not limited to: a. Living Will-A document that specifies a resident's preferences about measures that are used to prolong life when there is a terminal prognosis. b. Do Not Resuscitate- - Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) have directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used . 6. Changes to or revocations of an advance directive must be submitted in writing to the administrator. The care plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. Copies of changes to an advance directive must be filed in the resident ' s medical record located at the nurses' station . Further review of the facility's policy regarding advanced directives did not provide evidence that the facility established procedures for readmission from another healthcare provider that specify how the facility would determine if there was a change regarding a resident's preferences for treatment options that may have occurred during a hospitalization . An observation on [DATE] at 9:35 AM revealed a code was in progress for a resident that resided in the facility. Further observation revealed that facility staff called 911 and the Emergency Medical Team arrived and went to the room of the resident. An observation on [DATE] at approximately 9:50 AM revealed a family member running towards the nurses' station stating in a loud voice He (Resident #85) was a DNR (Do Not Resuscitate)! Didn't (S12MD) send it? The family was then observed going back towards the resident's room and it was noted that two additional Emergency Medical Team members arrived with critical care equipment and went to the hall that the resident resided on. Review of the hard chart for Resident #85 lying on the desk behind the nurses' station revealed no documentation of a DNR status or orders noted in the chart. Review of the facility's Electronic Health Record for Resident #85 revealed there was a form titled: Do Not Resuscitate (DNR) Status Acknowledgement (Family) for resident #85 that read: Patient Name: Resident #85 Date: [DATE] Time: 1449 I (We), (Resident #85 's daughter) for Resident #85, am (are) aware of and understand that a Do Not Resuscitate order has been written in Resident #85's medical record. I (we) am (are) aware that I (we) can revoke this Do Not Resuscitate status at any time by simply expressing my (our) request verbally or in writing to Resident #85's physician. Being of sound mind, I (we) do voluntarily agree with the Do Not Resuscitate Order, and I (we) understand its full import, after thorough explanation by a physician with an opportunity to ask all questions. Signatures of Patient Representatives: (Resident #85's daughter); [DATE]; Relationship- daughter-R (Responsible) Party Attestation of Witnesses The individual (s) who has /have signed this form appear(s) to be of sound mind, and under no duress, fraud, or undue influence. Two witness signatures were noted on the form. During an interview on [DATE] at 11:05 a.m., S1DON (Director of Nursing) was asked to explain the facility's process for acknowledgement of a DNR status of a resident that returns from the hospital. S1DON stated that when residents returned from the hospital with a DNR status or there was a family request for DNR, the facility should get the family together to get all consents signed by family and then get consents from physicians to make sure that the DNR order was done as requested. S1DON stated that the facility's policy was to get a signature from two physicians for a terminal prognosis and for DNR status. The DON was asked how the facility was notified when the family requested a change in code status while the resident was in the hospital, and S1DON stated that if they already knew the family's wishes, the family could meet with the facility before the resident returned from the hospitalization . She stated that they always have all the children of the resident involved unless there was a Power of Attorney (POA). She stated that if family makes a request at the hospital, then the facility would contact all family members, one physician signature sometimes came from the hospital and then the second signature was obtained from S10MD (Medical Doctor), who was the Medical Director. She stated that S10MD's signature could be obtained every day, even if needed on a Friday night. She stated that if a DNR status was requested in the hospital, then the facility depended on the Case Managers at the hospitals to contact S7SS (Social Services) to inform her of the DNR request from the family or of the code status change to DNR. The DON stated that the DNR status of the resident was placed inside the hard chart so that when anyone looked at the chart, they would know. She revealed that they were implementing a new procedure to mark the name on the outside of the resident's door with a yellow highlight. S1DON revealed that either she or S8ADON (Assistant Director of Nursing) reviewed all hospital records and any paperwork from hospitals, including the extended care hospital, and the information that was pertinent was scanned into the electronic health record system. She indicated that S15WC (Ward Clerk) scanned all information from the hospitals after they were reviewed by herself or S8ADON. She stated that if she saw a family request for DNR status on a resident or anything that indicated a change in a resident's code status during the hospitalization , she would call the physician and her and S7SS would obtain the DNR together. S1DON denied Resident #85 having a DNR order or a Family Request for a DNR. She revealed that she did not recall seeing a family request for DNR for Resident #85 and could not completely recall discussing DNR with the family and she stated that if it was done it would be documented in the electronic notes. On [DATE] at 11:26 AM, S1DON confirmed that there was no documentation of the DNR status of Resident #85 being addressed. She stated that if there was a family request for a DNR status for Resident #85, then the facility should have gone through with the process of obtaining the DNR order from the doctor. On [DATE] at 11:31 AM, S1DON reviewed a copy of the Do Not Resuscitate (DNR) Status Acknowledgement (Family) form for Resident #85 printed from the facility's Electronic Health records for the resident. After review of the form S1DON stated that she did not see the form and if she would have seen the form, then the DNR order would have been obtained from the doctor. S1DON confirmed that the Do Not Resuscitate (DNR) Status Acknowledgement (Family) form for Resident #85 was scanned and placed in the facility's electronic health record system and according to the facility's process for review of hospital records, this DNR form was reviewed by either herself or S8ADON for any new orders or changes before the records were scanned into the system. During an interview on [DATE] at 11:45 AM, S8ADON confirmed she was responsible for reviewing hospital records when a resident was readmitted to the facility. S8ADON confirmed that she did not notice the form when she reviewed the hospital records for Resident #85. During an interview on [DATE] at 11:50 AM, S7SS (Social Services) revealed that she was responsible for obtaining all paperwork and orders for DNR (Do Not Resuscitate). She stated that upon admission to the facility, the DNR status was discussed initially with the family and resident, again if there was a change in the resident's condition, and then periodically. She stated that if a resident was hospitalized and the DNR status changed then she would be notified by the hospital, the physician, or the family. She stated that she worked with the paperwork that was provided by the hospital and then she contacted the family and the physician to ensure that everyone was in agreement. She confirmed that she did not see the Do Not Resuscitate (DNR) Status Acknowledgment (Family) form dated [DATE] for Resident #85 until minutes ago when it was brought to her attention. Review of the facility's list of residents that have DNR status revealed that Resident #85 was not listed among the residents. During an interview on [DATE] at 2:09 p.m., Resident #85's daughter revealed that she signed for the DNR form for her father approximately 2 months ago when her father was in the Intensive Care Unit during a previous hospitalization . Resident #85's daughter confirmed that CPR was started at the facility earlier today and it should not have been. She revealed that it was Resident #85's wishes that he not be resuscitated. She revealed that the facility knew that her father was a DNR because she spoke to the nurse, who was an agency nurse, when Resident #85 was readmitted to the facility from the extended care hospital. Resident #85's daughter also revealed that she spoke to S7SS (Social Services) regarding her father's DNR on the same day that he was readmitted from the extended care hospital. She indicated that S7SS was on her way to lunch when she informed her that her father was a DNR. Review of the hospital records revealed the DNR Order Form dated [DATE] timed 0840 for Resident #85 revealed the form was signed by the physician, a registered nurse, and two of the resident's daughters. Further review of the DNR order form revealed Do Not Resuscitate was checked and Physician has discussed 'DNR' with patient and/or family. Review of the Hospital Progress Notes dated [DATE] at 9:19 AM, [DATE] at 8:45 AM, and [DATE] at 10:05 AM written by S12MD (Medical Doctor) revealed documentation in the notes that Patient is DNR. During an interview on [DATE] at 10:45 AM, S1DON reviewed the facility's policy titled Advanced Directives. She stated that there were no written procedures of what the facility followed for advanced directives other than the Advanced Directives Policy. Review of the Advanced Directives Policy did not address a change in code status that may have occurred during a hospitalization and how the facility would address the change upon readmission to the facility. S1DON stated that when residents were admitted to the hospitals, including extended care hospitals or psychiatric hospitals, the hospital staff usually told us if the residents were DNRs. She stated that when paper work was received from the hospital, she and S8ADON also look through the hospital records. When asked about the reference in the Advanced Directives Policy, #6 regarding, Changes to or revocations of an advance directive must be submitted in writing to the administrator, S1DON stated that either she or S7SS were to make a written notification to the Administrator if the Resident or Family revoked or wanted to change status. S1DON stated that she and S7SS were responsible for keeping up with the code statuses of all of the residents and for making sure that the information was easy access to the nursing staff. On [DATE] at 10:00 AM, S1DON stated that the documentation regarding Resident #85's DNR status came in the Hospital Return Packet and S8ADON received this packet, reviewed it, and the information was then scanned into the electronic health record system for Resident #85. S1DON stated that she reviewed the physician's orders [REDACTED]. S1DON stated that S8ADON should have looked thoroughly at what was scanned. She stated that S8ADON should have seen the Do Not Resuscitate (DNR) Status Acknowledgement (Family) form for Resident #85 dated [DATE] and should have brought it to her (S1DON) attention so that she could act upon the Acknowledgement. S1DON stated that she would have questioned S12MD and then questioned the family to see if this is what they really wanted to do. S1DON stated that, It was something that slipped through. During a telephone interview on [DATE] at 1:30 PM, S10MD (Medical Doctor) confirmed that he was the medical director for the facility. S10MD stated that the facility should have identified that the family of Resident #85 had initiated a DNR status when they received the documentation from the other facility. S10MD stated that Someone should have picked that documentation up; they should have identified it, and acted upon it when they received it in the return documentation sent to the facility from the extended care hospital with the DNR wishes of the family on it. S10MD further stated that he should have been notified regarding the DNR desire by Resident #85's family. Resident #19: Review of the clinical records for Resident #19 revealed the resident was originally admitted to the nursing home on [DATE]. Review of the MDS dated [DATE] for Resident #19 revealed her BIMS (Brief Interview for Mental Status) was scored as a 15 out of 15, which indicated the resident was Cognitively Intact. Review of the electronic health record for Resident #19 revealed hospital progress records, from (Extended Care Hospital), dated [DATE], [DATE] and [DATE] with a code status of DNR (Do Not Resuscitate) documented on each progress note. Review of the social services entries for Resident #19 dated [DATE] through [DATE] revealed no documentation regarding the code status. Review of the hard copy chart for Resident #19 revealed a form titled Advance Directive Declaration dated [DATE] was signed by Resident #19. Review of the physician orders [REDACTED].#19 did not reveal a DNR order. Review of the Care Plan for Resident #19 revealed she was care planned for a Living Will with the interventions noting the documents are on the Resident ' s chart and the Living Will for Resident #19 will be reviewed and followed. During an interview on [DATE] at 10:15 AM with Resident #19, she reviewed and confirmed that the signature on the Advance Directive Declaration dated [DATE] was her signature. She further stated that when she dies I want to die quickly. During an interview on [DATE] at 10:45 AM, S1DON (Director of Nursing) was asked about Resident #19's code status. S1DON confirmed that Resident #19 was not include on the DNR status list because she was not terminal at this point and she had a living will. She stated that for her last hospitalization ([DATE]) when she was in the (extended care hospital) the nurse approached the resident regarding a DNR status and the resident was undecided about a DNR status and she signed the paper and was instructed by the nurse at the extended care hospital that they would do everything to save her if it came to that point. S1DON stated that Resident #19's daughter told them that she signed the paper but did not want to make the decision to be a DNR at that time. S1DON confirmed that Resident #19's DNR status was addressed with Resident #19's daughter yesterday ([DATE]) evening. During an interview on [DATE] at 12:30 PM, S7SS (Social Services) stated that Resident #19 signed a Living Will on [DATE] and She is a Living Will for right now. During the interview, S7SS stated Whenever there is information on a resident's code status from an outside facility, S8ADON (Assistant Director of Nursing) goes through the paperwork and informs me of any changes or if there is anything that I need to address. After reviewing the progress notes of [DATE], [DATE] and [DATE] for Resident #19 from the (extended care hospital), S7SS stated that she sees the documents have identified the code status as DNR. She stated she had not seen these documents before and added that she doesn't recall S8ADON telling her about a code status change for Resident #19. During the interview, S7SS submitted a typed document dated [DATE] that she stated Resident #19 ' s daughter typed expressing her mother's wishes. S7SS confirmed that she spoke to Resident #19's daughter last night on [DATE] regarding her mother's stay at the (extended care hospital) in [DATE] and had her clarify her mother's code status. S7SS indicated that she asked Resident #19's daughter to type the statement regarding her mother's code status last night. She confirmed it was not addressed following the August hospitalization until last night. A review of a typed and signed document dated [DATE] by the daughter of Resident #19 read: the resident is capable of making the decision regarding the Living Will and when it is to be activated. During an interview on [DATE] at 2:37 PM, S8ADON, the progress notes for Resident #19, dated [DATE] through [DATE] from the extended care hospital were reviewed by S8ADON at which time she confirmed I am sure I saw the progress notes if I scanned them and having DNR documented in the progress note would not have alerted me to refer this to S7SS because it is a progress note not a physician order. S8ADON confirmed that she had scanned the documents for Resident #19. S8ADON stated I have had conversations with Resident #19 and know she wants to have everything done to save her unless she is in a coma. After reviewing the e-chart, she confirmed that she had not documented these conversations with the resident or any clarification of the discrepancy in code status. During an interview on [DATE] at 2:13 PM, Resident #19's daughter confirmed her mother had a Living Will at the facility and her mother had always told her that if she had a terminal disease [MEDICAL CONDITION] that she would not want to be on a respirator. Resident #19's daughter reviewed the progress noted from the extended care hospital dated [DATE] through [DATE] and stated The nursing home never told me about the DNR documentation at the extended care hospital and seeing this documentation concerns me because I know what my mother wants. Resident #19's daughter denied discussions of her mother's DNR status with the facility while she was hospitalized in [DATE] or upon readmit to the facility. During a phone conversation on [DATE] at 1:30 PM with S10MD (Medical Doctor), he confirmed that he was the medical director for the nursing home facility. He confirmed that Resident #19 had been a patient at the extended care hospital and that although he was on staff there, he usually allows the attending physician to see the residents during an extended stay hospitalization . S10MD stated that he did not see Resident #19 while she was a patient at the extended care hospital and was not aware the physician had documented she was a DNR on the extended care progress notes. He stated If the resident had a previous Advanced Directive in this facility and the facility received information that reflected they were a DNR upon return from another facility, the residents ' status should have been clarified by the facility. S10MD stated I ask routinely about a DNR status when a resident is declining or hospitalized frequently. S10MD stated The nursing home should have notified me of the DNR documentation received from the (extended care hospital) upon Resident #19's return to allow me to address the resident's code status and they had not. He added That should have been brought to my attention for clarification with the resident and her family. During an interview on [DATE] at 10:45 AM, S1DON confirmed that the facility should have addressed the DNR status on the progress notes in [DATE] and should have documented that it was addressed. She confirmed that there was no documentation that the code status was discussed with Resident #19, who is cognitive, or with the family prior to [DATE], and there should have been documentation.

Based on record review and interview, the facility failed to ensure that each resident's physician was notified of a possible change in code status when the facility failed to notify the physician that documents forwarded to the facility after a hospitalization at an extended care hospital identified the resident with a DNR (Do Not Resuscitate) status, for 1 (#19) of 20 (#9, #18, #19, #23, #33, #47, #51, #52, #64, #69, #76, #85, #87, #90, #96, #99, #115, #118, #131, #135) residents reviewed for change in code status upon readmission to the facility after a hospitalization . The facility had a total of 122 residents. FINDINGS: A review of Resident #19 ' s hard copy chart revealed a document titled Advanced Directive Declaration, which was dated 10/29/2012 signed by resident #19. On the document, the resident declared that if she should have a terminal or irreversible, incurable injury, disease or illness, or if she was in a continual profound stat (Sic.) with no reasonable chance of recovery, she wanted none of the following: bagging, intubation, chest compressions, defibrillation, cardioversion, ACLS (Advanced Cardiac Life Support) drugs, or artificial feeding. A review of the resident ' s electronic record revealed hospital progress notes from an extended care hospital dated 8/1/15, 8/2/15, and 8/3/15 with code status DNR handwritten on them. A review of the care plan revealed that the resident has a living will documented on her chart and that staff was to: Review resident's living will and ensure it is followed. On 10/30/15 at 12:30 PM, an interview was conducted with S7SS (Social Services). She confirmed that the resident had signed a living will in the facility on 10/29/12, and told her that in the event that the she (resident) would become totally or irreversibly ill and got to where she was just lying in the bed and could not have an active life, then she did not want anything done to artificially extend her life. S7SS further stated that the resident had been in an extended stay hospital from 7/17/15 through 8/7/15, and that she returned to the nursing home on 8/7/15. On 10/30/15 at 2:37 PM, an interview was conducted with S8ADON (Assistant Director of Nursing). She confirmed that Resident #19 had signed a living will in the facility prior to being hospitalized at an extended stay hospital. The resident returned to the facility on [DATE] from the extended stay hospital, and S8ADON stated that she had scanned the hospital documents regarding the hospital stay into the resident ' s nursing home electronic record. S8ADON stated that if she would see that a resident had returned to the facility with a No Code order from another facility, she would pull the documents out and bring them to S7SS so that S7SS could see about them and speak to the residents ' family. S8ADON further stated that she was sure that she saw the hospital progress notes from the extended stay hospital dated 8/1/15 through 8/3/15 as she had scanned them into the electronic chart. She further stated that she would not notice DNR on the progress notes as something that needed to be addressed because it is not an order, it is a progress note. On 11/2/15 at 1:30 PM, a telephone interview was conducted with S10MD (Medical Director) and he confirmed that he was the medical director for the facility. He confirmed that Resident #19 had been a patient at an extended care hospital and then returned to the nursing facility. S10MD stated that he had not been made aware that Resident #19 ' s physician at the extended care hospital had documented that the resident was a DNR on the extended care progress notes. He stated that if Resident #19 had a previous Advanced Directive in this facility and the facility received information that reflected that they were a DNR upon return from another facility, the resident ' s code status should have been clarified by the facility. S10MD stated that the facility staff should have notified him of the DNR documentation received from the extended care hospital upon Resident #19 ' s return to allow him to address the resident ' s code status and they had not. He further stated that it should have been brought to his attention for clarification with the resident and the family.

Based on observation, interview, and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#85) of 20 (#9, #18, #19, #23, #33, #47, #51, #52, #64, #69, #76, #85, #87, #90, #96, #99, #115, #118, #131, #135) residents reviewed for change in code status upon readmission to the facility after a hospitalization when S7SS (Social Services) failed to acknowledge a family's verbal notification of DNR status (#85). Findings: Resident #85: An observation on [DATE] at 9:35 AM revealed a code was in progress for a resident that resided in the facility. Further observation revealed that facility staff called 911 and the Emergency Medical Team arrived and went to the room of the resident. An observation on [DATE] at approximately 9:50 AM revealed a family member running towards the nurses' station stating in a loud voice He (Resident #85) was a DNR (Do Not Resuscitate)! Didn't (S12MD) send it? The family was then observed going back towards the resident's room and it was noted that two additional Emergency Medical Team members arrived with critical care equipment and went to the hall that the resident resided on. At 10:10 AM on [DATE], the resident was observed being wheeled on a stretcher by the Emergency Medical Team, as they provided rescue breathing with a bag valve mask, out of the facility and he was placed in an ambulance. During an interview on [DATE] at 2:09 PM, Resident #85's daughter revealed that she signed for the DNR form for her father approximately 2 months ago when her father was in the Intensive Care Unit during a previous hospitalization . She confirmed that she and her sister signed it and a copy of it was sent to the attending physician, S12MD (Medical Doctor). Resident #85's daughter stated that she again signed a DNR for her father (Resident #85) when he was transferred to the extended care hospital to ensure that the staff would not resuscitate him but would keep him comfortable. She revealed that she did not have legal power of attorney, but her other siblings did not want to handle being responsible and they gave her the authority to conduct Resident #85's business and she was the Responsible Party for her father. She stated that the decision for the DNR was in agreement by all of her siblings. She revealed that Resident #85 had seven living children. She revealed that her decision had not changed about him being a DNR and she stated that she wished that they would not have put him on the ventilator. Resident #85's daughter confirmed that CPR was started at the facility earlier today and it should not have been. She revealed that it was Resident #85's wishes that he not be resuscitated. According to Resident #85's daughter, she received a phone call from the Nursing Home that her father may have had a seizure and that they were going to take him to the hospital and she could meet them there. She stated that she went to the Nursing home and when she arrived they were performing CPR on her father. She indicated that she asked them to stop because he was a DNR. She stated that she was told that they did not have a DNR on Resident #85 and it was protocol that they had to continue. Resident #85's daughter revealed that her father was intubated and placed on a ventilator and she finally got them to take him off of the ventilator. She revealed that the facility knew that her father was a DNR because she spoke to the nurse, who was an agency nurse, when Resident #85 was readmitted to the facility from the (extended care hospital). Resident #85's daughter also revealed that she spoke to S7SS (Social Services) regarding her father's DNR on the same day that he was readmitted from the (extended care hospital). She indicated that S7SS was on her way to lunch when she informed her that her father was a DNR. Resident #85's daughter stated that her father confided in her that he was tired. Review of the hard chart for Resident #85 revealed no documentation of a DNR status or orders noted in the chart. Review of the facility's Electronic Health Record for Resident #85 revealed there was a form titled: Do Not Resuscitate (DNR) Status Acknowledgement (Family) for resident #85 that read: Patient Name: Resident #85 Date: [DATE] Time: 1449 I (We), (Resident #85's daughter) for Resident #85, am (are) aware of and understand that a Do Not Resuscitate order has been written in Resident #85's medical record. I (we) am (are) aware that I (we) can revoke this Do Not Resuscitate status at any time by simply expressing my (our) request verbally or in writing to Resident #85's physician. Being of sound mind, I (we) do voluntarily agree with the Do Not Resuscitate Order, and I (we) understand its full import, after thorough explanation by a physician with an opportunity to ask all questions. Signatures of Patient Representatives: (Resident #85's daughter); [DATE]; Relationship- daughter-R (Responsible) Party Attestation of Witnesses The individual (s) who has /have signed this form appear(s) to be of sound mind, and under no duress, fraud, or undue influence. Two witness signatures were noted on the form. During an interview on [DATE] at 11:05 AM, S1DON (Director of Nursing) stated that if a DNR status was requested in the hospital, then the facility depended on the Case Managers at the hospitals to contact S7SS (Social Services) to inform her of the DNR request from the family or of the code status change to DNR. S1DON confirmed that the facility staff performed CPR (Cardiopulmonary Resuscitation) on Resident #85, activated EMS (Emergency Medical Services), and transferred Resident #85 to the hospital earlier today. During an interview on [DATE] at 11:50 AM, S7SS (Social Services) revealed that she was responsible for obtaining all paperwork and orders for DNR (Do Not Resuscitate). She stated that upon admission to the facility, the DNR status was discussed initially with the family and resident, again if there was a change in the resident's condition, and then periodically. She stated that if a resident was hospitalized and the DNR status changed then she would be notified by the hospital, the physician, or the family. She stated that she worked with the paperwork that was provided by the hospital and then she contacted the family and the physician to ensure that everyone was in agreement. She confirmed that she did not see the Do Not Resuscitate (DNR) Status Acknowledgment (Family) form dated [DATE] for Resident #85 until minutes ago when it was brought to her attention. S7SS revealed that if she had seen it previously then she would have contacted the family and physician to obtain the DNR order. She was given the Do Not Resuscitate (DNR) Status Acknowledgment (Family) form for review and after review she stated that the extended care hospital used that form as their facility's DNR status of residents. She revealed that Resident #85's daughter was not the legal Power of Attorney, but was the Responsible Party for Resident #85. S7SS confirmed that she was responsible for assisting in obtaining the DNR order. She stated that she would have assisted in obtaining the accurate DNR form that this facility used for Resident #85 if she was aware of the change in code status. S7SS stated that she depended on the hospital to verbally communicate a change in the DNR status. Review of the Electronic Social Service Notes dated [DATE] did not have documentation of DNR status of Resident #85 being addressed. Further review of electronic notes for social services did not provide documentation that the facility reassessed the code status of resident #85 after he was readmitted to the facility on [DATE].

Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior as evidenced by dirty air conditioner vent/filters in 4 Residents (Resident #41, #66, #106, #108) out of 10 (Resident #41, #56, #66, #67, #106, #108, #118, #120, #128, #146) Residents rooms observed. This area of deficient practice had the potential to affect 122 Residents according to the Resident Census and Conditions of Residents dated 10/26/15. Findings: An observation on 10/27/2015 3:00 PM revealed a green substance on the bottom of the air/heating vent in the room of Resident #106 & Resident #41. Observation of the air condition vent in the room of Resident #108 and Resident #66 on 10/27/15 at 3:19 PM revealed that the air conditioner vent/filter was dirty. During an interview at this time, Resident # 108 stated the air conditioner was cleaned and checked a couple of months ago. She further stated that every so often they come clean and check the air condition vent. An interview was held with S4CNA on 10/27/15 at 3:25 PM she confirmed that the air conditioner vent was dirty. An interview with S5LPN on 10/27/15 at 3:31 PM confirmed that the air conditioner vent was dirty. She further stated that she would have the Maintenance Supervisor clean the dirty air conditioner vent. During an interview on 10/28/2015 9:30 AM with S3Maintenance Supervisor confirmed the air conditioner filters were dirty in some rooms and should be cleaned once a month.

Based on observation, interviews, and record reviews, the facility failed to ensure 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents received adequate supervision to prevent accidents on 10/22/14. On 10/2/2014 Resident #1 sustained a head laceration that required 9 staples after she was found in her room on the floor. The facility's failure to ensure Resident #1 was supervised on 10/22/14 resulted in actual harm when the resident fell from her wheelchair, while unattended in her room a second time, and sustained another head laceration that required 11 sutures to close. According to the facility's Resident Census and Conditions of Residents form, the facility had a total census of 115 residents. Findings: Record review on 12/9/14 and 12/10/14 revealed that Resident #1 was admitted to the facility on [DATE]; and her birth date was listed as 6/16/1930 ([AGE] years old). Her [DIAGNOSES REDACTED]. Further review of Resident #1's record revealed documentation in a nursing note dated 10/2/14 at 18:30 (6:30 PM) that read in part, "...resident found per... CNA at this time lying on floor, resident awake and alert, speech low, laceration noted to frontal region with excessive bleeding, applied pressure to area until bleeding resolved, dressed area with NS (normal saline) 4x4's and kerlix... ambulance called at this time, will send resident to (local hospital) for eval (evaluation) and tx (treatment), will continue to monitor resident until ambulance arrive." Review of documentation in a nursing health status note dated 10/2/14 at 22:35 (10:35 PM) revealed the following, "... resident returned to home at this time, no acute signs of distress noted, resp (respirations) non-labored, placed in bed per... ambulance staff, tolerated well, skin warm and dry to touch, resident rips dressing off of forehead and begins rubbing area, 9 staples noted to laceration on residents frontal region, cleansed with NS, redressed 4x4's and tegaderm... DON... states to place resident with mittens in order to stop her from pulling staples, family aware of resident's status, mittens placed to hands... f/u (follow-up) with PCP (Primary Care Physician) 10-14 days MD notification prepared, neuro (neurological) checks continued, Tylenol administered per standing orders, safety maintained, will continue to monitor." Review on 12/9/14 of Resident #1's care plan revealed a revision dated 10/3/14 (the day after the fall on 10/2/14) to the care plan under the focus listed as, "At Risk for Injuries From Falls..." The revised interventions dated 10/3/14 read, "Resident not (to) be in room unsupervised when up in chair," and "Chair alarm in chair." Further review of documentation, that indicated the "author" as S6LPN, in the Nursing Health Status Note dated 10/22/14 at 5:40 AM revealed the following, "Sent to ER (emergency room ) for evaluation. CNA put res (resident) in wc (wheelchair) turned her back and res. fell face first onto floor causing large laceration, opening to forehead. Pressure applied. Amb (ambulance), Hosp (hospital), and family notified. Left per (ambulance)..." Review on 12/9/14 of the incident report dated 10/22/14 (5:23 AM) prepared by S6LPN revealed documentation of the description of the incident of the fall of Resident #1, "Called to room per CNA (S7). Stated she put res (resident) in w/c (wheelchair); turned her back for a second and res. (resident) fell forward onto floor causing large laceration to forehead. Pressure applied..." Review of documentation in a Nursing Health Status Note dated 10/22/2014 at 9:38 AM revealed the following, "Resident returned from (local hospital ) ER, resent (resident) has 11 sutures noted to forehead, clean laceration to forehead with normal saline, apply Bactroban and cover q day and PRN as needed until healed, remove sutures in 7 to 10 days, f/u (follow-up) with (physician) in 1 week, no bruising noted to eyes at present, will monitor, is on current neuro checks, no acute distress noted at present." Review on 12/9/14 of the record of Resident #1 revealed the following fall assessments: Fall Risk assessment dated [DATE] indicated total score of 13 (10 or more represents High Risk); Fall Assessment Post Fall (dated 10/3/14) utilizing Morse Fall Scale indicated total score of 30.0 (Moderate Risk for Falling); and Fall Assessment Post Fall (dated 10/22/14) utilizing Morse Fall Scale indicated total score of 55.0 (High Risk for Falling). Review of Resident #1's quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 7/8/2014 revealed that the resident was unable to complete the Brief Interview for Mental Status (BIMS); and her Cognitive Skills were moderately impaired (decisions poor; cues/ supervision required). Review of Resident #1's quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/7/2014 revealed Extensive Assistance (resident involved in activity, staff provide weight bearing support) for Bed Mobility; and Total Dependence for transfer; locomotion on unit; locomotion off of unit; toilet use; and personal hygiene. On 12/9/14 at 12:15 PM, Resident #1 was observed in bed with nonsensical conversation. A healed scar was evident on her forehead. An interview was conducted with S7CNA on 12/9/14 at 1:12 PM. S7CNA stated that on the day of the incident around 5:30 AM that she got Resident #1 out of bed; and put in wheelchair. S7CNA stated that she walked right outside of the door to get towels for the shower; and resident fell out of wheelchair. S7CNA replied, "It happened so fast." During interview on 12/9/14 at 2:45 PM of S6LPN, S6LPN reported that she was called to the room of Resident #1; and the resident was on the floor and had a laceration on her forehead. S6LPN stated that S7CNA had placed the resident in her wheelchair for a shower in her room. S6LPN stated that S7CNA went to the door to get towels from the cart, right on the outside of the door of the room; and that's when resident leaned forward and fell . S6LPN replied that was unusual because resident doesn't usually move. Review on 12/10/14 of the written statement of S7CNA dated 10/25/14 revealed the following in part as related to the incident with Resident #1 on 10/22/14, "... I put (name of Resident #1) in her wheelchair for a shower I walked out the room for a few seconds when I walked back in the room she was on the floor... (Resident #1) had fallen out of her chair..." On 12/10/14 at 1:55 PM, an interview was conducted with the Administrator (ADM), S1. S1ADM stated that she realized that after the first fall incident (on 10/2/14) that the resident (#1) should not have fallen in that manner again (fall on 10/22/14) S1ADM confirmed that staff left Resident #1 unattended in her room in the wheelchair on 10/22/14 which resulted in harm when the resident fell and sustained a head laceration. On 12/10/14 at 2:35 PM, an interview was conducted with S2Director of Nursing (DON). S2DON stated that she thought that the problem of the resident (#1) falling had been addressed with the revisions of the plan of care but unfortunately staff turned away for that short while; and the resident (#1) fell again.