Every finding on record at Fairfield Memorial Hospital

Based on interview and record review the facility failed to ensure equipment was maintained in a safe functional manner to ensure resident safety for one (R3) of five residents reviewed for falls in a sample of 17. This failure caused R3 to receive five staples in R3's head. Findings include: R3's Medication Review Report documents diagnoses including: chronic kidney disease, age related osteoporosis, major depressive disorder, displaced bicondylar fracture of right tibia, and heart failure. R3's admission/registration record documents a admitted [DATE]. R3's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief interview of mental status) score of 13 indicating R3 is cognitively intact. R3's care plan's focus area documents: R3 is a high risk for falls relating to weakness. On 10/15/24 at 9:50 AM, R3 stated she fell while she was transferring in the shower room. R3 stated , The chair moved and the girl tried to catch her but she is little, she could not hold me and I hit my head and had to get staples put in my head. R3 stated, it did hurt for a while, when her head would hit the pillow. On 10/17/24 at 10:50 AM, R3 stated she thinks there was problems with the wheels on the shower chair before but she does not completely remember. On 10/17/24 at 10:57 AM, V8 (Certified Nurse Aide/CNA) stated she assisted R3 with her shower when she fell . V8 stated R3 was in the shower chair and while she was putting a mechanical standing assistive device under her the shower chair kept moving. V8 stated she had already locked the brakes on the shower chair but it moved anyway. V8 stated she tried to catch R3 the best she could. V8 stated she turned the call light on and tried to hold R3 until someone else came to help. She stated she did not use that shower chair often, she preferred the other chair but the other chair was in use. V8 stated the standing assist device moved also because when R3 fell she had her feet on it and she pushed it when she fell . R3's post fall evaluation dated 07/22/2024 at 2:16 PM documents: fall details: date/time of fall: 07/22/2024 at 2:00 PM fall was witnessed; who witnessed fall: (V8); fall occurred elsewhere; fall location: shower, activity at the time of fall; transferring from the shower chair to the mechanical stand assist, reason for the fall was evident, reason for the fall; both pieces of equipment moved and the floor was very wet, the pre-fall: fall risk score was 8, post-fall; the fall risk score is 8. Did an injury occur as a result of the fall: yes, injury details; the resident hit her head on the frame of the door as she was lowered to the floor, she turned her head to the right side, the back of her head causing a quarter size goose egg to her head with a minor scrape and bleeding. Did the fall result in an ER (emergency room ) visit/hospitalization ; no. (R3's) provider is (V11 (physician)), time notified: 07/22/2024 and she was notified of the fall and the resident hitting the back right side of her head. The fall details note; (V8) was transferring the resident from the shower chair to the mechanical standing assist chair when both chairs went out from under the resident. CNA (V8) lowered the resident to the floor. The resident hit the right side of the back of the head on door the frame causing a quarter size goose egg with scraped skin with minor bleeding. R3's Progress note dated 7/22/24 at 4:07 PM documents R3 was sent to ER via wheelchair and two staff members. R3's Health status note dated 07/22/2024 at 5:40 PM documents: (R3) returned to the unit via a WC (wheelchair) and was accompanied by staff from ER. Sm (small) laceration to the back of the head, right parietal area with 5 staples in place. Sm (small) mt (amount) of oozing blood was noted. Staples are to be removed in 5 days. R3 had Tylenol and clonidine in ER for the pain and elevated BP (blood pressure). R3's Progress note dated 07/23/24 documents: pain: indicators of pain: vocal complaints of pain, location: parietal region (top of back of skull), pain score is documented as a 6, cool compresses applied, non-medication interventions provided relief. R3's Progress note dated 07/24/24 at 10:08 PM documents: day 2 post fall with an injury to the head, 5 staples remain in place with no sign of infection is noted, there is moderate pain and occasional headaches but (R3) states Tylenol helps. On 10/17/24 at 11:14 AM, V10 (CNA) stated she did not typically use the pink shower chair, she would typically use the other chair. R3 fit better in the pink chair but she just liked the other chair better. V10 stated she believes they have put new wheels on the chair before but she does not remember it not working before the day R3 fell . They have removed the chair from use now. On 10/17/24 at 11:43 AM, V7 (Maintenance) stated it was reported to him on 07/22/24 there was a broken shower chair, on 07/26/24 they were informed there were no parts available so the chair was removed from inventory, on 07/31/24 the new shower chair arrived and was put together, on 08/01/24 the new chair was delivered to the 3rd floor. V7 stated, when they received the original chair, one brake worked and one brake didn't, that is why it would slide on a wet floor.

Based on interview and record review the facility failed to provide a Medicare written notice regarding of the resident's potential liability for a non-covered stay for 2 of 3 residents (R5, R16) reviewed for Beneficiary Protection Notification in the sample of 17. Findings include: 1. R5's Medication Review Report documents diagnoses including: displaced trimalleolar fracture of right lower leg, aphasia following cerebral infarction, and neuropathy. R5's admission/registration record documents a admitted [DATE]. R5's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief interview of mental status) score of 00 indicating severe cognition impairment. R5's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form documents a discharge from Medicare Part A services prior to exhaustion of his benefit day allotment. This form documents that a written notice of the resident's potential liability for a non-covered stay (SNFABN - CMS (Center for Medicare Services) 10055) form was not provided to R5 to explain her right to appeal the decision of discharge from Medicare Part A services prior to exhaustion of her benefit days. R5's Medical record does not contain a CMS 10055 document. 2. R16's Medication Review Report documents diagnoses including: stable burst fracture of fourth lumbar vertebra, wedge compression fracture of unspecified thoracic vertebra, type II diabetes mellitus, and dementia. R16's admission/registration record documents a admitted [DATE]. R16's Minimum Data Set (MDS) dated [DATE] documents a BIMS score of 06 indicating severe cognitive impairment. R16's SNF Beneficiary Protection Notification Review form documents a discharge from Medicare Part A services prior to exhaustion of his benefit day allotment. This form documents that a written notice of the resident's potential liability for a non-covered stay (SNFABN - CMS10055) form was not provided to R16 to explain her right to appeal the decision of discharge from Medicare Part A services prior to exhaustion of her benefit days. R16's Medical record does not contain a CMS 10055 document. On 10/17/24 at 1:45 PM, R16 stated she does not remember if she received any forms about her therapy days. On 10/17/24 at 1:45 PM, V3 (Care plan coordinator/Minimum Data Set Coordinator) stated they do not have the form (CMS 10055) for R5 or R16, they read the instructions incorrectly and they did not give the CMS 10055 they only gave the NOMNC (Notice of Medicare Non-Coverage) form.

Based on observation, interview, and record review the facility failed to implement treatment and services to prevent a decline in range of motion for 1 of 1 (R8) residents reviewed for position and mobility in the sample of 17. Findings Include: R8's Admission/Registration Record dated 12/29/23 documents R8 was admitted to the facility on [DATE]. R8's Medication Review Report dated 10/17/24 documents R8's diagnoses include Alzheimer's disease, anemia, dementia, and anxiety disorder. R8's MDS (Minimum Data Set) dated 9/19/24 documents R8 has a severe cognitive impairment. This same MDS documents under Section GG, R8 is dependent on staff for bed mobility and transfers and does not ambulate. R8's current Care Plan documents a Focus area of (R8) has limited physical mobility. (R8) has poor sitting balance and leans forward while in chair. Date Initiated: 12/29/2023 This same Focus area includes the following interventions, May have reclining wheelchair to help while positioning. Date Initiated: 10/16/2024. The resident is Weight-bearing, pivot transfer. Date Initiated: 12/29/2023. Locomotion: The resident is totally dependent on 1 staff for locomotion using wheelchair. Date Initiated: 01/09/2024 .Nursing Rehab/Restorative: Passive ROM (range of motion) Program #1 Nursing to perform passive ROM to BUE (bilateral upper extremities) BLE (bilateral lower extremities) x (times) 15 reps every day. Date Initiated 10/16/24 .Nursing Rehab/Restorative: Resident to tolerate 2 hours up in chair daily. Date Initiated: 10/16/2024 On 10/16/24 at 1:50 PM, R8 was observed in bed turning from back to side, with no assistance from staff. V6 (Caregiver) stated R8 will support her weight when they transfer her from bed to chair and will assist with pivoting to the next surface. V6 stated as far as she knows R8 is not being provided with any restorative programs or therapy services. On 10/16/24 at 1:58 PM, V3 (MDS Coordinator) stated R8 does not have a restorative program in place. V3 stated therapy usually writes the programs and she thinks it just got missed. R8's Medication Review Report dated 10/17/24 includes the following orders with a start date of 10/16/24, Restorative plan- Patient to tolerate 2 hours up in chair daily. Restorative plan- Nursing to perform passive ROM (range of motion) to BUE (bilateral upper extremities) BLE (bilateral lower extremities) x (times) 15 reps daily. R8's Medication Review Report does not document orders for restorative programs prior to 10/16/24. The facility Nursing Administration policy dated 8/2024 documents under 4. Restorative Nursing: a. Restorative nursing procedures will be carried out on all residents who require them. b. Nursing personnel will accomplish restorative nursing procedures through the following nursing measures .c. Nursing's goal is to rehabilitate each resident to his maximum capability and to maintain his highest level as long as he may live

Based on interview and record review, the facility failed to offer pneumococcal vaccinations for 2 of 5 residents (R7, R6) reviewed for immunizations in a sample of 17. Findings include: 1. R7's Admission/Registration Record documents an admitted [DATE] and a date of birth (DOB) indicating R7 is [AGE] years of age. R7's Medication Review Report documents diagnoses including: chronic kidney disease, epilepsy and type I diabetes mellitus. R7's Immunization Record in the medical record documents: Prevnar 13 was administered on 11/28/17 and Prevnar 23 was administered on 02/06/2019 under immunization record section. A document titled Immunization Status and Vaccine Consent with dates for Influenza consent of 09/03/24, refusal for Covid vaccination dated 09/04/24 and a refusal for RSV(respiratory syncytial virus) immunization dated 09/03/24 contains a blank section for the pneumonia vaccine refusal or consent. The Centers for Disease Control (CDC) Immunization Schedule https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo) documents for adults age 65 or older who have: Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. There is no documentation in R7's medical record any pneumococcal vaccination was offered or administered. 2. R6's Admission/Registration Record documents an admitted [DATE] and a date of birth (DOB) indicating R6 is [AGE] years of age. R6's Medication Review Report documents diagnoses including: Gastro esophageal reflux disease without esophagitis, essential hypertension, seasonal allergic rhinitis, and dementia. R6's Immunization Record in the medical record documents: Prevnar 13 was administered on 11/04/17 and Prevnar 23 was administered on 11/14/2018 under immunization record section. The Centers for Disease Control (CDC) Immunization Schedule https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo) documents for adults age 65 or older who have: Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. There is no documentation in R6's medical record any pneumococcal vaccination was offered or administered. On 10/16/24 at 1:10 PM, V3 (Care plan coordinator/Minimum Data Set Coordinator) stated she was under the impression if a resident previously had the Prevnar 13 and Prevnar 23 their pneumococcal vaccination series was complete. The facility policy dated 01/24 titled, Nursing Administration with the subject listed as: Pneumococcal Pneumonia Immunization documents: Purpose: To reduce the overall incidents pneumococcal pneumonia by providing the pneumococcal pneumonia vaccine to all residents [AGE] years of age and older and to others at high risk.

Based on observation, interview, and record review the facility failed to lock wheelchair brakes and use a gait belt needed for safe transfer of a resident for 1 of 3 (R2) residents reviewed for falls in a sample of 3. This failure resulted in R2 sustaining a right leg fracture requiring surgical intervention. This past noncompliance occurred from 7/7/22 to 7/11/22. Findings include: R2's face sheet documented R2 was admitted to the facility on [DATE]. R2's face sheet documented diagnoses included: heart failure, [CONDITION(S)], [CONDITION(S)], and major depressive disorder. R2's 6/29/22 Minimum Data Set (MDS) showed R2 was cognitively intact and required extensive one person assist with transfers. R2's 6/29/22 Fall Risk Assessment showed a score of low risk for falls. An undated final report sent to the department by V1 (Director of Nursing/DON) documents in part, On the morning of 07/07/2022, V2, Certified Nursing Assistant/CNA was providing care for R2. It was R2's shower day and she reports that she was being rushed by V2. R2 reported that V2 told her they only had 5 minutes to complete her bath. R2 then said to V2 we can wait till after breakfast. V2 responded to her we have to do it now. Upon returning to R2's room, R2 reports that V2 was rushing her to stand up from the wheelchair so she could walk to her recliner. V2 did not lock the brakes, or use a gait belt. V2 attempted to stand her by lifting up on her arm. The wheelchair rolled backwards and R2 fell to her knees on the floor. R2 states she immediately told V2 that she was injured and felt like she had broken her legs. R2 was transferred to (name of local)Emergency Department, where x-rays revealed that she had a Right unstable tibia plateau fracture. On 07/07/2022 R2 went to surgery at (name of local hospital) where V5 (Physician) did a right knee closed reduction with external fixator placement. She was then transferred to the med/surg unit for monitoring. R2 came back to (facility unit) on 07/11/2022 with orders for PT/OT (physical therapy/occupational therapy)to eval and treat, nwb (non-weight bearing) to the right leg, and pain management. On 7/19/22 at 1:15 PM, R2 was lying in bed with external hardware and dressings visible to the right leg. R2 said on 7/7/22, V2 (CNA) assisted R2 to the shower. R2 said V2 was in a hurry and told R2 we can get this done in 5 minutes. R2 stated after my shower we (R2 and V2) got back to my room. She (V2) put my walker in front of me and grabbed me by the arm. She (V2) jerked me up and I lost my balance and went down on my knees. It felt like she broke both my legs. R2 said after being transferred to the emergency room she had surgery to repair a fracture to the right leg. R2 said this experience was very painful and R2 was still in pain after the surgical repair. On 7/19/22 at 1:25 PM, V3 Registered Nurse (RN) said she was the nurse caring for R2 on 7/7/22. V3 said she was receiving morning report when she heard a housekeeper call for help. V3 said she entered R2's room R2 was lying on the floor on her back around the foot of her bed and was hysterically screaming. V3 said R2 was complaining of bilateral leg pain. V3 said R2 was being assisted by V2 (CNA) from the wheelchair to the recliner. V3 denied R2 having a gait belt on. V3 said a mechanical lift was used to assist R2 to the bed for transfer to the emergency department. V3 said R2 said she felt rushed and told V2 to slow down she was going to fall. V3 said when transferring a resident, a gait belt should always be used. V3 said when transferring a resident from a wheelchair the brakes should always be locked before transferring. On 7/19/22 at 2:10 PM, V4 (CNA) said a gait belt should always be used when transferring a resident. V4 said when transferring a resident from a wheelchair the brakes should always be locked before transferring. V4 said gait belts are readily available through out the facility for staff use. V4 was familiar with the facility fall prevention policy. On 7/19/22 at 10:30 AM, V1 (DON) said she was the person that investigated R2's 7/7/22 fall. V1 said V2 did not use a gait belt to assist with R2's transfer and did not lock the brakes of wheelchair prior to R2's transfer resulting in R2 falling sustaining a right tibia fracture. V1 said V2 was no longer employed at the facility. On 7/19/22 at 2:20 PM, V1 said she expected staff to follow facility policies when transferring residents. V1 said a gait belt should have been used and the wheelchair brakes should have been locked prior to the R2's transfer. R2's 7/7/22 fall investigation documented in part .Nursing Description: Called to resident's room by housekeeper. Resident heard yelling out, She broke my legs! She broke my legs! Lying flat on back. c/o pain in bilateral legs. States, I've broken both legs before and I never cried. I know their broke! Hysterical and tearful. Asked, Where am I, am I on the floor? Resident had returned from shower in wheelchair and was being transferred in room with walker back to recliner. No gait belt in use. Slipper socks on . Immediate Action Taken . order received to transfer to ER (emergency room ) . and V2's Director of Nursing (DON) notes showed .Spoke with [R2] in ER. States [V2 Certified Nurse's Assistant (CNA)] was bringing her back from the shower room where [V2] had rushed her stating she only had five minutes to do the shower. On the way back from the shower [V2] stopped w/c (wheelchair) at the end of the bed, did not lock brakes, [R2] stated w/c rolled, attempted to lift her by her arm, [R2] stated - [V2] slow down and [R2] fell to her knees. [R2] Says she immediately knew her leg was broken and told [V2] you have broken my legs. [R2] stated there was no gait belt on her at the time of any transfers . R2's 7/7/22 hospital record's Nurse's Notes documented in part .Presenting Compliant: [V3 (RN)] . brought patient to ER via gurney. [V3] states patient was being assisted with getting a shower and back to her wheelchair when fell to her knees. Patient immediately stated that she was having severe pain in her bilateral lower legs. Patient states she feels like her legs are broken . Triage Assessment: . Pain: complaints of pain to right shin pain currently is 10 out of 10 on a pain scale . Musculoskeletal: . range of motion limited in right knee and right ankle Bony deformity noted in right shin Swelling present in right shin . Assessment: patient reports that the CNA came to her and said that she had five minutes to get her shower and rushed her getting back to her wheelchair. Then when she was trying to get in the wheelchair she stated the CNA was telling her to come on come on and the patient was trying to hurry then she fell to her knees. She reports she told the CNA she broke her legs. [V3] That brought patient to ER states patient is usually a standby assist and this morning she was getting out of the shower when she fell and she was unable to bear any weight at all after the fall . [Medical Provider] here to see patient. He states he will be doing surgery on her right leg today . R2's 7/7/22 hospital record's titled Diagnostic Imaging Femur Minimum 2 View X-Ray report documented in part, . communicated and impacted transverse intercondylar fracture of the right tibia with depression of the lateral tibial plateau . R2's 7/7/22 hospital record's titled Diagnostic Imaging Tibia and Fibula 2 View X-Ray report documented in part . 1. right lateral tibial plateau displaced fracture . R2's hospital record's 7/7/22 titled Report of Operation documented in part, .Procedure Performed: Right knee closed reduction with uniplanar external fixation . Reason for Procedure: . fell this morning and landed on her right lower leg. Again, she ambulates very minimally but was unable to bear any weight whatsoever after the incident. Further workup revealed a . tibial plateau fracture. Due to the unstable nature of the injury and to ease the patient's pain, the above surgery was recommended to the patient . The benefits of the surgery were discussed with the patient including stabilization of an unstable fracture which would alleviate pain . R2's hospital record's 7/8/22 titled Diagnostic Imaging CT LO EXTREM W/O CON (Computed topography lower extremity with out contrast) documented in part . 1. Comminuted mildly displaced proximal tibia fracture extending into the lateral tibial plateau which is mildly depressed. An external fixation device has two pens within the proximal tibia. 2. 11.5 x 2.0 x 5.2 cm hematoma anterior to the tibia within the subcutaneous fat The facility's May 2022 Procedure for Use of Gait Belt policy documented in part, .A gait belt is to be used at all times when transferring/ ambulating a patient/ resident . The facility's April 2022 Fall Prevention Program policy documented in part, . Skilled Care Unit . Possible Nursing Interventions to Reduce the Risk of Falls . 10. Establish a safe room . lock brakes on furniture . The facility's January 2022 Safe Patent Handling and Movement Policy documented in part, . Patient Handling and Movement Requirements . 3. Use . approved patient handling aids in accordance with instructions and training . Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. On 7/19/22 at 10:30 AM, V1 (DON) said after R2's 7/7/22 fall incident the facility held an all staff meeting on 7/11/22 with an inservice/ education on proper transfers, including the locking of the wheelchair brakes before transferring residents, the use of gait belts, and therapy to offer as needed inservices/ education to staff. V1 also stated they held a Quality Assurance meeting after this happened to go over this specific topic. The facility's 7/11/22 Continuing Education form showed .In-House Inservice . use of gait belt, therapy to offer as needed inservices/ education . and had 20 staff signatures present.

Based on record review and interview, the facility failed to ensure the attending physician documented a rationale in the medical record for the use of a PRN (as needed) anxiolytic for an extended time period (beyond 14 days) for one of 7 residents (R5) reviewed for unnecessary medications in the sample of 12. Findings include: R5's Face Sheet documented an admission date of [DATE] and a date of birth of 08/16/39, making R5 [AGE] years of age. R5's March 2020 Physicians Order Sheet documented an order for [REDACTED]. R5's Medication Administration Record [REDACTED]. On 03/06/20 at 9:32 am, V1, Director of Nurses, stated that R5 is seen by R5's provider every 30 days. V1 stated in the last 90 days, R5 has had four doses of the PRN [MEDICATION NAME]. V1 confirmed the 11/08/19 order was open ended and had no discontinuation date. A PRN [MEDICAL CONDITION] Medication Policy dated 4/18 stated, Purpose: To ensure all PRN [MEDICAL CONDITION] medications are used effectively and (to) avoid overuse, and given within the parameters that are laid out within federal and state guidelines All PRN [MEDICAL CONDITION] medication orders will have the medication name, dose, specific reason for use, and a maximum use of 14 days, then discontinue PRN use. Notify physician for new orders.

Based on observation, interview, and record review, the facility failed to ensure privacy was maintained during personal care services for 1 (R217) of 4 residents reviewed for privacy in the sample of 18. The Findings Include: On 05/28/19 at 10:00 AM, a security camera was observed in R217's room, appearing to be pointed towards resident bed area. On 5/28/19 at 10:15 AM, a security camera monitoring screen was observed present in nurses station. The screen showed active monitoring surveillance of residents within their rooms, including R217's room. There was no privacy screen observed being present over the camera monitoring screen, making the screen potentially visible to anyone within the nurses station. On 05/28/19 at 01:21 PM, V4 (Registered Nurse, RN) states the only viewing monitor for the patient room surveillance cameras is located at the nurses station. On 5/29/19 at 03:13 PM, V1 (Skilled Care Unit Manager / RN) states the surveillance cameras within resident's rooms do not record, but provide a way for staff to view resident activities as a way to maintain safety for high risk fall residents. A facility policy titled, Placement of a Monitoring Device in a Patient's / Resident's Room as a Safety Precaution, with a revision date of (MONTH) 2012 states, (Facility Name) is responsible for maintaining a safe and secure environment for all patients / residents. Those patients / residents who are unable to communicate needs or are unable to use a call light may have a monitoring device placed in their room to enable the nursing staff to monitor them continuously for their needs and safety. A facility policy titled Perineal Care with a Review date of (MONTH) (YEAR), documents in Procedure step 3. Provide Privacy (pull curtain - door closed). On 05/29/19 at 12:38 PM, V5 (Certified Nurse Assistant, CNA), and V6 (CNA / Unit Secretary) were observed toileting R217 via bedside commode in R217's bedroom. V5 was observed closing R217's bedroom door prior to providing care. Although a privacy curtain was observed as being present in R271's room, it was not pulled. R217's private areas were exposed while being sat on / sitting on commode. During continuous observation at nurses station where the security camera monitoring screen was present, fell ow surveyor verified the care being provided to R217, in which R217's private areas were exposed, and visible on the security camera monitoring screen. On 05/29/19 at 01:37 PM, V2 (Social Services) was observed working in nurses station within viewing range of camera monitoring screen. On 05/29/19 at 03:23 PM, V3 (Pharmacist) was observed working in nurses station within viewing range of camera monitoring screen. On 5/30/19 at 11:45 PM, V7 (RN) states that many hospital staff entities including speech / physical / occupational therapy, dietary, pharmacy, nursing staff, information technology, etcetera, along with contracted vendor services such as for copier repair are individuals who may be present, and she has observed being present in the nurses station, where the resident surveillance monitoring screen is present. On 05/29/19 at 1:04pm, V9 (Family Member) states she is in favor of having a camera in R4's room due to R4 having a history of falls and R4 not being able to use her call light due to having Dementia. When asked how she would feel if non-nursing staff, or outside vendors such as pest control contractors had access to the area where the surveillance camera monitoring screen was located , V9 states she is confident that staff would pull the privacy curtain to obscure the cameras view of care. On 05/30/19 at 09:52 AM, V5 states it is the expectation for staff to provide resident privacy while providing resident care, such as range of motion, or personal care. V5 states privacy is provided by closing the bedroom door, and having services be performed and viewed only by the staff providing the care. On 5/30/19 at 12:37 PM, V1 states it is her expectation that staff provide privacy for residents with surveillance camera's in their room while receiving personal care, so care being provided is not visible on the surveillance monitoring screen located in the nurses station. V1 states an example of how privacy could be provided during resident care is by staff utilizing the privacy curtain to protect the resident from the camera's view. On 5/30/19 at 1:54 PM V1 states that R217 is a new admission to the facility. V1 states R217 has been been in her present room, with active resident surveillance camera monitoring since admission due to her history of falls. R217's Admission / Registration Record documents R217 was admitted to the facility on [DATE]. On 05/31/19 at 08:57 AM, V8 (Family Member) states he is aware of of the surveillance monitoring camera in R217's room, and is ok with its use. V8 states he was informed of the cameras purposed use upon R217's admission for safety enhancement, signed the consent to allow the camera's use, and has no concerns. V8 states although he is ok with the camera surveillance monitoring's use, he would expect privacy to be maintained for R217.

Based on record review and interview, the facility failed to: a) ensure that 2 of 6 residents (R8 and R16) reviewed for pneumococcal immunizations had the opportunity to receive the 13-valent pneumococcal conjugate vaccine (PCV13, or Prevnar 13 (brand name)) and b) failed to develop policies and procedures to include current standards of practice to ensure residents who were eligible were offered the 13-valent pneumococcal conjugate vaccine which would minimize the risk of residents acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. This had the potential to affect all 18 residents residing in the facility. The findings include: 1. On 4/3/18, R8's written medical record stated R8 was admitted to the facility on [DATE]. The medical record included R8's Immunization Record which documented under Immunization History - [MEDICATION NAME] last received - 2011. There was no further documentation regarding this immunization. 2. On 4/3/18, R16's written medical record stated R16 was admitted to the facility on [DATE]. The medical record included R16's Immunization Record which documented under Immunization History - [MEDICATION NAME] last received blank. The comment section states: unknown date received in last 5 years per son. There was no further documentation regarding this immunization. The facility's (MONTH) (YEAR) Pneumococcal Pneumonia Immunization Policy states: All resident admitted to the Skilled Care Unit will be screened to determine eligibility for the pneumococcal pneumonia vaccine by obtaining immunization history. The facility's (MONTH) (YEAR) Pneumococcal and Influenza Vaccination for Long Term Care Residents states: In an effort to prevent serious infections, all long term care residents shall be offered pneumococcal and influenza vaccinations. The documents fail to address the types of pneumococcal vaccinations available or recommended by current standards of practice. On 04/03/18 at 2:49 PM, V2 (Chief Nurse Executive) and V3 (Pharmacist) stated that the facility has used the PCV13 for two years. On 4/5/18 at 1:25pm, V4 (Registered Nurse, Care Plan Coordinator) stated that she could not find further documentation regarding pneumonia immunizations for R8 or R16. V4 indicated she had no rationale for why the residents were not offered the available immunizations. Review of current CDC (Centers for Disease Control) recommendations, available at: <https://www.cdc.gov/features/adult-pneumococcal/index.html> indicated the following: CDC recommends 2 pneumococcal vaccines for all adults [AGE] years or older. -You should receive a dose of PCV13 first, followed by a dose of PPSV23, at least 1 year later. -If you already received any doses of PPSV23, get the dose of PCV13 at least 1 year after the most recent PPSV23 dose. -If you already received a dose of PCV13 at a younger age, CDC does not recommend another dose. Review of the ACIP (American Committee on Immunization Practices) Recommendations for PCV13 and PPSV23 (pneumococcal [MEDICATION NAME] vaccine) Use, available at <https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm>, indicated Adults with specified immunocompromising conditions who are eligible for pneumococcal vaccine should be vaccinated with PCV13 during their next pneumococcal vaccination opportunity. The recommendation also included the following: Pneumococcal vaccine-naive person age 65 or greater: PCV13 then 6-12 months later, PPSV23. Persons who previously received PPSV23 at age 65 or greater: PCV13 at or after 1 year of PPSV23. Persons who previously received PPSV23 before age 65: PCV13 at age 65 or greater or after 1 year of PPSV23, then PPSV23 6-12 months after PCV13. The Residents Census and Conditions of Residents form dated 4/2/18, documents a census of 18 residents residing at the facility.

Based on observation, interview, and record review, the facility failed to maintain a shower room floor in good repair. This has the potential to affect 4 of 8 residents (R2, R4, R5, R7) reviewed for environment in the sample of 8 and 4 residents (R9, R10, R11, R12) in the supplemental sample. The findings include: On 7/5/2016 at 1:10 pm., floor tiles were missing in two areas of the floor in the west end shower room measuring approximately 4 by 6 and 1 by 6. This creates a rough and uneven floor surface. On 7/7/2016 at 1:00 pm. R5 stated that these tiles have been missing since R5 was admitted , it has been reported twice and R5 believes this is a hazard. On 7/8/2016 at 11:30 am, E4, Maintenance Coordinator, stated that the facility is currently awaiting a bid for the replacement of all the tiles in this shower room. According to a list provided by the facility on 7/8/2010, R2, R4, R5, R7, R9, R10, R11, and R12 are the residents who use the west end shower room.

Based on observation, interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's functional status for one of eight residents (R1) reviewed for MDS assessments in the sample of 8. The findings include: R1's History and Physical, dated 7/18/15, documents, in part, a [DIAGNOSES REDACTED]. R1's MDSs dated 4/6/16 and 6/24/16 both document under section G, Functional Status, Section G0110 Activities of Daily Living (ADL) Assistance, that R1 is total dependence with 2 person physical assist for transfers and that walking in room and corridor did not occur for R1. These same MDSs, under Section 0400, Functional Limitation in Range of Motion, documents that R1 has No Impairment to Upper extremity and Lower extremity. The Center for Medicare Services, Resident Assessment Instrument, Version 3.0 Manual documents on Page G-34, under section G0400: Functional Limitation in Range of Motion, definition of functional limitation in range of motion (ROM) as the limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury. It also states, when completing this item, staff should refer back to item G0110 and view the limitation in ROM taking into account activities that the resident is able to perform. On 7/5/16 at 1:25PM, R1 was being transferred from her bed to her motorized wheelchair with a mechanical lift. On 7/5/16 at 11:55AM, R1 said that she hasn't walked in years. On 7/8/16 at 10:00AM, E3, Minimum Data Set/ Care Plan Coordinator, stated that she coded R1's MDS (Section 0400, Functional Limitation Range of Motion) at a zero because R1 had no contractures. E3 went on to say that she interpreted it as a function of the joint but now understands that it is a function that prevents them from performing ADLs.

Based on observation, interview and record review, the facility failed to update the care plan for urinary catheter use for one of one resident (R1) reviewed for urinary catheters in the sample of 8. The findings include: R1's April, 2016 Physician order [REDACTED]. On 7/5/16 at 1:35PM, R1 had a urinary catheter in place and catheter care was being provided. On 7/5/16 at 1:50PM, E6, Registered Nurse (RN) said R1 pulls at her urinary catheter and that her catheter leaks and comes out easily. E6, RN went on to say that R1 has a large size (24 French with a 30 cubic centimeter balloon) urinary catheter in place but that it still comes out easily and leaks. On 7/7/16 at 10:30AM, E5, Certified Nurse Aide (CNA) was assisting R1 with Passive Range of Motion but R1 did not have her urinary catheter in place. At this same time, E5 confirmed that R1 did not have a urinary catheter in place and that R1 had probably pulled it out again. E5 went on to say that R1 did not have a urinary catheter anchoring device in place because R1 does not like the anchoring devices and will pull them off. On 7/8/16 at 11:30AM, R1 was noted to have a urinary catheter in place. At this same time, R1 stated that she does not like those bands around her legs to hold the catheter tubing in place and that sometimes the catheter just comes out. R1's April, 2016 Treatment Record documents R1's urinary catheter was inserted on 4/4/16 and was reinserted again on 4/24/16. R1's May, 2016 Treatment Record documents R1's urinary catheter was replaced on 5/17/16 and again on 5/22/16. R1's June, 2016 Treatment Record documents R1's urinary catheter was replaced on 6/17/16 and again on 6/25/16. R1's July, 2016 Treatment Record documents R1's urinary catheter was replaced on 7/7/16. R1's Nurses Notes, dated 7/7/16 at 10:15AM, documents in part, patient pulled urinary catheter out with bulb partially inflated. No trauma noted. R1's Care Plan, with a Problem of At Risk of Urinary Tract Infection due to Indwelling Urinary Catheter has a start date of 4/4/16 but does not address R1 pulling out her urinary catheter or of R1 refusing to wear a urinary catheter anchoring device. On 7/8/16 at 10:00AM, E3, Minimum Data Set/ Care Plan Coordinator stated R1's urinary catheter was initially inserted on 4/4/16 and was to be changed once a month. At this same time, E3 said according to R1's Treatment Record, R1 has pulled out her catheter several times each month. E3 went on to say that R1 does not like a catheter anchoring device. At this same time, E3 stated that she did not address on R1's care plan that R1 refuses the anchoring device or that R1 pulls out her urinary catheter. E3 then said, I guess I should have.

Based on observation, interview and record review and interview the facility failed to maintain all air conditioners in a sanitary manner. This has the potential to affect all 20 residents in the facility. The findings include: The facility's Resident Census and Conditions of Residents form, dated, 9/15 /14 documented the facility had a census of 20 residents. 1. A tour on 9/16/14 beginning at 1:40 PM found the following air conditioners with a black substance clinging to the adjustable vent grates and the insulation behind the grates. a) Resident rooms: 303, 305 and 316 b) Common Dining Room All of the units were in operation at the time of the observations. 2. The units were rechecked on the morning of 9/18/14 at 10:00 AM, and found to be somewhat cleaner. The black substance was less noticeable. However, the black remained on some of the insulation and tiny crevices on the grates. 3. On 09/16/14 at 2:30 PM, E1 (Nurse Manager) and E14 (Chief Nurse Executive) stated, "The Housekeeping Supervisor had cleaned the vents the evening of 09/16/14".

Based on observation, and record review the facility failed to prevent cross contamination by keeping urinary catheter tubing off of the floor, and during emptying of a catheter bag for one of one resident (R6) reviewed for preventing cross contamination during catheter bag care in the sample of eight. Findings include: 1. R6 was observed sitting in a chair in his room on 09-16-14 at 1:15 PM . R6's urinary bladder catheter tubing was noted on the floor. At 1:30 PM, E4 (Certified Nurse Aide) was observed to place a plastic container on the floor without a barrier. E4 opened and closed the catheter port without cleaning the end of the port, both before and after emptying the urine from the catheter bag. R6's urinalysis dated 08-18-14 indicated he had a urinary tract infection. R6's physician order [REDACTED]. The Collecting Urinary Output from Foley Catheters Policy and Procedure (Reviewed-October, 2013) states: #2. The catheter bag and tubing should never be raised above the bladder or allowed to touch the floor. #4. A barrier (Such as a paper towel) should be placed on the floor to sit the collecting container on. #5. The drain spout should be cleansed with alcohol prior to opening the drain, and should not come in contact with the collecting container.

Based on interview, observation, and record review the facility failed to provide monthly pharmacy review that include treatment medications and safe storage of medications. This has the potential to effect all of the 20 residents living in this facility. The findings include: 1. On 10/29/13 during record review for R 3's, R 5's, and R 6's past medication treatment records, it was noted the pharmacist initials indicating review, were absent. During an interview with E 3 (Pharmacist) on 10/29/13 at 1:00pm E3 stated he does not check the treatment record and does not check the medications obtained from outside sources for resident treatment use. E 3 stated it would be nice but it is not done here. 2. On 10/29/13 at 10:00AM during observation of the medication cart with E 2 (Registered Nurse) a tube of hemorrhoid cream was observed in R 9's oral medication drawer. E 2 stated the family of R 9 brought the tube of hemorrhoid cream in over the weekend. Because there is no order for the hemorrhoid cream it was placed in the oral medication drawer until they could decide what to do with it. The Resident Census and Condition of Residents dated 10/28/13 documents the facility has a census of 20 residents.

Based on observation,interview, and record review the facility failed to properly handle and disinfect the blood glucose monitor and monitor case for 1 of 1 residents (R2) reviewed for blood glucose monitoring in the sample of 5 and 5 residents (R 9, R 10, R 11, R 12, and R 13) in the supplemental sample. The findings include: 1. On 10/29/13 at 1030 AM E 2 (Registered Nurse) took the blood glucose monitoring device case from the medication room shelf and placed it on top of the medication cart. The blood glucose monitoring device case was then taken to R 9's room and placed on the resident's overbed table without a barrier. After the blood glucose monitoring was performed the case and monitor were taken to the medication room and placed on the medication cart without a barrier. The blood glucose monitor was cleaned for 15 seconds with one germicidal disposable cloth and placed in the blood glucose monitor device case. The case was then placed on the medication room shelf. 2. During an observation on 10/29/13 at 10:53 AM, E 2 (Registered Nurse) removed the blood glucose monitoring device case from the medication room shelf and placed on top of the medication cart. The blood glucose monitoring device case was then take to R 10's room and placed on the resident's overbed table without a barrier. After the blood glucose testing was performed the monitoring device and case were returned to the medication room. The case was then placed on the medication cart without a barrier. The monitor was cleaned with a germicidal disposable cloth for 15 seconds and placed in the blood glucose monitoring device case. The case was then placed on the medication room shelf. 3. The Cleaning/Disinfecting Glucometer policy, dated October 2013 documents the following procedure: To disinfect use a germicidal disposable cloth, use a second cloth to thoroughly wet surface, and allow to remain wet at least 5 minutes and allow it to air dry. 4. At 4:30 PM on 10/30/13 E1 (Nurse Manager) provided a list of all residents (R2, R 9, R10, R11, R12, and R13) recieving blood glucose monitoring in the facility. The facility has one blood glucose monitor for residents use.

Based on record review and interview the facility failed to develop and implement written policies for internal abuse reporting, that include immediate reporting to the Administrator. This has the potential to affect all 20 residents living in the facility. The finding includes: The Resident Census and Condition of Residents dated 10/28/13 documents the facility has a census of 20 residents. 1. A review of the facility's Reporting/Investigating Resident Abuse policy (dated as reviewed, October 2013) was reviewed on 10/29/13 and found to include on page 2 under Procedure: "1. Any individual who has a reason to believe that physical abuse, mistreatment or neglect has occurred must immediately be removed from the abusive environment and notify their immediate Supervisor." 2. An interview with E6 (Certified Nurse Aide) conducted on 10/29/13 at 10:55am, found when asked about abuse reporting, E6 identified the Nurse Manager or Charge Nurse. Further, when asked about an abuse scenario E6 indicated that the Nurse Manager or Charge Nurse would be notified immediately. 3. An interview with E5 (Registered Nurse) conducted on 10/28/13 at 2:25pm found when asked about abuse reporting E5 indicated E1 (Nurse Manager) would be notified. E5 did not indicate the need to notify the facility Administrator during the interview. 4. An interview with E4 (Director of Organizational Development) on 10/30/13 at 1:00pm confirmed that the facility policy originally presented to the surveyors indicated in the Policy section page 1 states in part... "Any individual who has reason to believe that physical abuse, mistreatment, or neglect has occurred must immediately notify their immediate supervisor." At that time, E4 further indicated that the revised policy was corrected to include immediate notification of the Administrator.

Based on observation, record review, and interview the facility failed to ensure food is served under sanitary conditions. This has the potential to affect all of the 20 residents living in the facility. Findings include: 1. During lunch observation at 10:55AM on 11-14-12: a) The steam table and plate lowerator was observed blocking the hand sink in the service kitchen on the Skilled Care Unit. During resident tray preparation and delivery the staff did not have access to the sink to wash their hands. b) The steam table was observed uncovered in the service kitchen which is part of the resident dining room. The dietary staff prepare resident's plates on the West side of the steam table with the East side open to the dining room. There was no food guard to protect the food items on the steam table from contamination by staff, residents or visitors when approaching the steam table on the East side to obtain resident trays or observe food items. The blocking of the hand sink and the risk of contamination of food on the steam table was confirmed during interview with E6, (Dietary Manager), at 12:00PM on 11-14-12. 2. During an observation of the dietary storage and food preparation areas on 11/13/12 at noon the following areas were in need of cleaning and maintenance: a) The light shields and ceiling around the circular vents in the preparation and service areas were very soiled with thick dust. b) The area around the circular vent in the ceiling above the food service area was noted to be bulging and the ceiling material was peeling. The Resident Census and Conditions of Residents Form CMS 672 completed by E3, (Registered Nurse), on 11-13-12 notes a census of 20. E6 stated at the time of the observation that the area would need to be cleaned and repaired.

Based on record review and interview the facility failed to ensure timely physician's visits for 1 of 8 residents (R4) reviewed for physician's visits in the sample of 8 and 1 resident (R9) in the supplemental sample. The findings include: 1. A review of admission records and physician's progress notes for R4 indicated the following: R4's admission records state an admission date of [DATE] and the only physician's progress note available regarding R4 is from 8/27/12. 2. A review of admission records and physician's progress notes for R9 indicated the following: R9's admission records state an admission date of [DATE] and the most recent physician's progress note is from 7/2/12. Further review of the visits and notes for R9 found the previous physician's visit for R9 was from 12/7/11. (a span of 6 months between visits). 3. Interview with E1 (Director of Nursing) at 3:30pm on 11/14/12 found that both R4 and R9 are patients of Z1 (Doctor). E1 indicated that Z1 does at times come to the 3rd floor skilled care unit and residents also visit Z1's office in the adjacent building.