Every finding on record at Fisher Senior Care and Rehabilitation

Based on interview and record review the facility failed to ensure that advance directives were updated in a timely manner and explained in clear language for one resident (Resident #42) of one resident reviewed for code status.Findings Include:Resident #42:On [DATE] at 9:15 AM, a review was conducted of Resident #42's medical record and it revealed she was admitted to the facility on [DATE] with diagnoses that included Anxiety, Intellectual Disabilities and Dementia. Resident #42 her own responsible party. Further review of record yielded the following:Physician Orders:DNR-Do Not Resuscitate - placed on [DATE]Code Status Form:On [DATE] Signed by Resident #42, two physicians and two witnesses that .in the event my heart and breathing stop, no person shall attempt to resuscitate me.Care Plan: .Advance Directives have been discussed & the following has been decided DNR. I am my own decision maker .Care Conferences:[DATE]: .Care plan and code status reviewed, and she wishes to remain a CPR (Cardiopulmonary Resuscitation) .XXX[DATE]: .Care plan and code status reviewed, and she wishes to remain a CPR.XXX[DATE]: .Care plan and code status reviewed, and she wishes to remain a CPR. It can be noted Resident #42 updated her code status in 2025 to CPR and it was never updated in the order set or care plans. During three care conferences, spanning nine months, she indicated her wishes for CPR designation that were not followed. On [DATE] at 9:40 AM, an interview was conducted with Social Worker D regarding Resident #42's code status. She stated she did not recall if she alerted anyone that her code status changed after Care Conference and she cannot update orders. Social Worker D was asked with the resident's diagnosis of intellectual disability does she fully understand the difference between CPR and DNR. She expressed there was a recent cognitive decline, and they were petitioning for a guardian on her behalf and its plausible it was not explained clear enough for Resident #42.Social Worker D (in the presence of this writer) asked Resident #42 if she understood what CPR meant and she asked the social worker to explain it to her. She proceeded to explain if she stopped breathing if she wants staff to pump her chest and she stated yes. It was apparent Resident #42 did not fully comprehend what was being asked. Social Worker D stated she would follow up with her. On [DATE] at 12:35 PM, Social Worker D stated she spoked to Resident #42 and explained CPR (pushing on chest) versus DNR (want to go peacefully) in their totality and what would occur in each scenario. She stated, oh no, she would not want them to push on her chest and would like to go peacefully. They are going to leave her as a DNR. Social Worker D stated during care conferences she does not believe Resident #42 understood the discussion and she (Social Worker) did not do a good job with explaining code status in clear language at her level of comprehension, Review was conducted of the facility policy entitled, Advance Directives, revised [DATE]. The policy stated, .The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident.changes or revocations of a directive must be submitted in writing to the Administrator.

Based on observation, interview and record review the facility failed to ensure that oxygen was administered as ordered for 1 resident (Resident #43) of 1 resident reviewed for respiratory care. Findings Include: Respiratory Care Resident #43:A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #43 was admitted to the facility on [DATE] with diagnoses: Respiratory failure, Primary Pulmonary hypertension, Emphysema, COPD, dependence on supplemental oxygen, and heart failure. The MDS assessment dated [DATE] revealed the resident had full cognitive ability with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with care. On 4/13/2026 at 1:28 PM, Resident #43 was observed sitting in her room in a wheelchair. She had on a nasal cannula connected to an oxygen concentrator that was set at 6 Liters/L of oxygen per minute. There was no humidification bottle to provide moisture that would aid in preventing her nose from becoming dried out. Resident #43 was asked about her oxygen settings, and she said it had recently changed. The resident was asked about her oxygen use, and she said she needed it and had been using it for a while. A review of the physician orders for Resident #43 identified the following: O2 at 5 L via NC (nasal cannula) continuously, start date 11/24/2025. A review of a Physician's Note for Resident #43 dated 4/6/2026 at 7:46 PM provided, . Dependence on supplemental oxygen. Pulmonary: O2 at 5L via NC continuously. A review of the Care Plans for Resident #43 provided the following: Potential/actual alteration in oxygen exchange r/t copd, osa, oxygen dependence, hypercapnic (high carbon dioxide levels) (respiratory) failure, emphysema, date created and started 11/24/2025 and revised 3/25/2026 with Interventions including: O2 as ordered: 5L via Nasal Cannula as ordered, date created and initiated 11/24/2025 and revised 2/16/2026. On 4/14/2026 at 12:05 PM, Resident #43 was observed resting in bed. Her oxygen concentrator settings were viewed with Registered Nurse J. When asked what the oxygen was set to, she said it was set at 6L/minute; it was observed to be set at 6L a minute. Nurse J was asked about humidification use with the oxygen because it was set at a higher dose and she said, she said they usually they waited to add it unless the resident complained of being dry. On 4/14/2026 at 12:10 PM, the physician oxygen order for Resident #43 was reviewed in the electronic medical record/emr with Nurse J; she said the order read 5L/minute via nasal cannula. A review of the facility policy titled, Oxygen Administration & Safety, origination date July 1, 2008 and effective date 6/7/17 provided, Purpose: Safe administration of oxygen therapy to the resident. Oxygen administration will be provided per physicians' order observing appropriate safety measures. Procedure: 1. Check physician's order for liter flow and method of administration.

Based on interview and record review the facility failed to provide a clinical rationale for administration of duplicate antidepressant therapy for two residents (Resident #4 & Resident #37) and ensure accurate indication for use of an antipsychotic medication for one resident (Resident #43) of seven residents reviewed for unnecessary medications.Findings Include:Resident #4: On 4/14/2026 at approximately 12:00 PM, a review was conducted of Resident #4's medical records and it revealed she readmitted to the facility on [DATE] with diagnoses that included, Metabolic Encephalopathy, Atrial Fibrillation, Major Depressive Disorder and Mood Disorder. Furter review of the record yielded the following:Physician Orders:Mirtazapine Oral Tablet 45 MG (milligrams) for Major Depressive Disorder- started on 9/13/2025Zoloft Oral Tablet 2.5 MG for Major Depressive Disorder. Ordered on 3/24/2026Review was conducted of Resident #4's nursing, physician and psychiatric progress notes were and there was no documentation located regarding Resident #4 usage of dual antidepressant therapy.On 4/14/2026 12:40 PM, Social Worker D was asked if there was any supporting documentation in chart related to Resident #4 need for dual antidepressant therapy. She reported she would look at her chart and follow up.On 4/15/2026 at 11:00 AM, Social Worker D stated she was unable to locate a risk versus benefits related to Resident #4's dual therapy but shared their physician was completing the needed documentation within 20 minutes. Resident #37:On 4/13/2026 at 3:30 PM, a review was conducted of Resident #37's medical record and it indicated she was admitted to the facility on [DATE] with diagnoses that included, Alzheimer's, Anxiety, Chronic Kidney Disease, Major Depressive Disorder and Insomnia. Further review yielded the following:Physician Orders:Trazadone HCl (hydrochloride) Oral Tablet 100 MG for Major Depressive Disorder - started on 9/12/2025Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 150 MG for Major Depressive Disorder - started on 3/24/2026Resident 37's nursing, physician and psychiatric progress notes were reviewed and there was no documentation located regarding Resident #4 usage of dual antidepressant therapy.On 3/14/2025 at 2:55 PM, Social Worker D reported Resident #27 was admitted to the facility on multiple psychotropic medications and they have been working to gradually reduce them. They are currently working on reducing the venlafaxine as their psychiatrist believes it is increasing the residents' anxiety. It was explained that while all this may be true, documentation regarding the reasoning for the current usage of dual antidepressant therapy is still required. Social Worker D reported from her review of the charting there was no supporting documentation for dual therapy located in Resident #37's chart. Resident #43:On 4/14/2026 at 2:00 PM, a review was conducted of Resident #43's medical records and it revealed the resident admitted the facility on 11/24/2025 with diagnoses that included Acute Respiratory Failure, Major Depressive Disorder and Pulmonary Hypertension. Further review of her records yielded the following:Physician Orders:Olanzapine Oral Tablet- for Major Depressive Disorder.According to the FDA (Food and Drug Administration) Olanzapine (Zyprexa) is an atypical antipsychotic indicated: As oral formulation for the: Treatment of schizophrenia. (1.1) Adults: Efficacy was established in three clinical trials in patients with schizophrenia.Acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder.Care Plan: .I have an alteration in my mood state r/t (related to) depression). I am ordered antidepressant and antipsychotic medication.On 4/14/2026 at 2:55 PM, Social Worker D reported Resident #43 admitted to the facility on Zyprexa and other psychotropics, as she was being followed by her local Community Mental Health (CMH). She was not agreeable to any medication changes until recently but there was no supporting documentation to this statement. The Social Worker was asked if she requested any of Resident #43's mental health documentation for her treatment team and she stated she did not. The social worker was asked if Major Depressive Disorder was an appropriate indication for use for Olanzapine and she stated it was not.Review was conducted of the facility policy entitled, Use of Psychotherapeutic Medications, revised 2/01/2025. The policy stated, . A resident will not receive psychotherapeutic medications unless such a medication is needed to treat a specific condition as diagnosed and documented in the clinical record with clearly defined target behaviors and non-pharmacological interventions are not effective. Duplicative drug therapy will be discouraged and closely monitored.

Based on observation, interview and record review, the facility failed to administer insulin per professional standards for one resident (Resident #43) of one resident reviewed for insulin administration, resulting in inaccurate site administration with the likelihood of malabsorption of insulin. Findings include. Resident #43: On 4/14/2026, at 8:26 AM, During medication administration task, Nurse K gathered morning medications for Resident #43 including their Insulin Glargine (Lantus) pen. Nurse K prepared the pen, entered the resident's room prepared the resident's right arm approximately 1 and 1/2 inches below the center of the deltoid muscle and injected the 10 units of insulin. On 4/14/2026, at 9:30 AM, Nurse K approached surveyor and asked if they did something wrong and Nurse K was asked if they felt where they injected the insulin pen/needle if there was enough subcutaneous tissue and Nurse K offered, the needle is so small. On 4/14/2026, at 1:45 PM, a record review of Resident #43's electronic medical record (EMR) revealed an admission on [DATE] with diagnoses that included Diabetes Mellitus, Heart failure Chronic Obstructive Pulmonary Disease. Resident #43 required assistance with Activities of Daily Living (ADL) and had intact cognition. A review of the Physician orders revealed Insulin Glargine Subcutaneous Solution 100 UNIT/ML (milliliters) (Insulin Glargine) Inject 10 unit subcutaneously (tissue located, occurring, or administered in the fatty layer directly beneath the skin) . On 4/14/2026, at 4:11 PM, Nurse Consultant B was alerted of the insulin pen administration observation for Resident #43 and was asked to provide the administration guidelines for insulin pens. Nurse Consultant B planned to educate Nurse K . On 4/15/2026, at 11:00 AM, a record review of the Lantus insulin glargine injection How to use your Lantus Solostar pen revealed areas to avoid . Only use the outer back area of the upper arm where there is fatty tissue .

Based on observation, interview and record review, the facility failed to ensure that Personal Protective Equipment (PPE) was worn during high contact care for one resident (Resident #4) of one resident reviewed for enteral feeding [a method of delivering liquid nutrients directly into the stomach via a percutaneous gastrostomy tube (PEG)], resulting in the likelihood of transmission of Multi-Drug Resistant Organisms (MDRO). Findings include:Resident #4: On 4/13/2026, at 3:30 PM, a record review of Resident #4's electronic medical record (EMR) revealed an admission on [DATE] with diagnoses that included feeding tube, Stroke and hypotension. Resident #4 required assistance with all Activities of Daily Living (ADL's) and had intact cognition. A record review of the Kardex revealed INFECTION Enhanced barrier precautions for MDRO prevention, includes gown and gloves for high-contact resident care activities . On 4/15/2026, at 8:54 AM, Prior to entry into Resident #4's room there was a 3-drawer caddy that housed PPE/gowns adjacent to the doorway and an enhanced barrier precautions sign on their doorway. Upon entry, Nurse I was observed standing on the left side of the bed with their knees touching the bed sheet. Nurse I was administering enteral feed solution via the Peg tube. Nurse I did not have on a protective gown. On 4/15/2026, at 8:56 AM, the Assistant Director of Nursing (ADON) A was asked if Nurse I should be wearing a protective gown while administering enteral feeding and ADON A stated, yes. On 4/15/2026, at 8:57 AM, an observation of Nurse I at the bedside of Resident #43 performing enteral feeding with no gown on along with ADON A was conducted. On 4/15/2026, at 8:58, ADON A exited Resident #43's room and offered the nurse would be educated. On 4/15/2026, at 11:00 AM, a record review of the facility provided Enhanced Barrier Precaution Policy Revision Date: April 1, 2024 revealed Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provided opportunities for transfer of MDROs to staff hands and clothing. High-Contact Resident Care Activities include: . Device care or use: . feeding tube .

Based on observation, interview and record review, the facility failed to ensure a clean and homelike environment for four residents (#'s 28, 37, 100, 101), of seven reviewed for environmental concerns, resulting in personal items not labeled with Resident identification, food not labeled with an open date or refrigerated and the potential for spread of infection and food borne illness. Findings include: Resident #28: On 2/11/25 at 12:16 PM, an interview was conducted with Resident #28 who was sitting up in their wheelchair. The Resident answered questions and engaged in limited conversation. The Resident had a bathroom that was shared with the room next door. There was not a resident in that room at this time. There were a pair of TED hose (Anti-Embolism stockings used to reduce the risk of deep vein thrombosis (blood clot)). The Resident was asked if he wore the TED hose and reported sometimes them put them on, not sure why they are not on at this time. The TED hose did not have a room number or Resident identification on them. On 2/13/25 at 12:11 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #28's TED hose. During record review, there was no order for the TED hose, no discharge order from the hospital for the TED hose, and no care plan in place for the TED hose. An observation was made with the DON of the TEDs in the bathroom that was shared with another resident in the next room. The TEDs did not have any resident name or identification of who they belonged to. Resident #37: A review of Resident #37's medical record revealed an admission into the facility on [DATE] with diagnoses that included urinary tract infection, stroke, and dementia. A review of the Minimum Data Set (MDS) assessment revealed moderately impaired cognition and was independent with eating and needed supervision or touching assistance with toileting hygiene, bathing, upper and lower body dressing and mobility of roll left and right and lying to sitting. On 2/11/25 at 10:40 AM, an interview was conducted with Resident #37 and Resident Representative G. The Resident answered some questions but answers were unreliable and the Resident Representative answered most questions and engaged in conversation. An observation was made in Resident #37's room of Resident #37's denture cup positioned underneath the towel dispenser. The denture cup was positioned that when taking paper towels out of the dispenser after washing hands, had the potential to come in contact with drips of water. On 2/12/25 at 12:10 PM, an observation was conducted with Resident #37 sitting on the side of their bed and had just received their lunch meal that was brought in by staff. The Resident had a bottle of cranberry juice that was partially used. The bottle had manufactures use by date but did not have a date of when the juice had been opened. The Resident did not have the cranberry juice in a cup at the bedside. The Resident was questioned about the juice but when asked when the juice had been opened, she indicated she was unsure what day the bottle was opened or how long she had the juice on her table. The Resident reported she preferred to have the juice cold but that it was not taken to the refrigerator and was left at the bedside. The Resident did not know who had brought in the juice for her. On 2/12/25 at 12:20 PM, an interview was conducted with Culinary Specialist H regarding facility policy of food brought into the facility. The Culinary Specialist indicated that the items should be dated when brought in and when opened and have a discard date. When asked about a juice bottle that was left on the Resident's bedside table, that was partially used, the Culinary Specialist reported that it should be refrigerated after being opened. An observation was made in the Resident's room of the juice opened and partially consumed. The Culinary Specialist indicated it should not be left opened and not refrigerated. Residents #100 and 101: On 2/11/25 at 11:40 AM, an observation was made in Resident #100 and 101's room. The two residents shared a room and bathroom. Resident #100 was sleeping at the time and Resident #101 was not present in the room. Resident #100 had a urinal on the bedside table that had urine inside. The urinal did not have a room number or identification on it. The bathroom had another urinal on the handrail that did not have any identification of the urinal of which resident it belonged to. On 2/13/25 at 3:00 PM, an interview was conducted with the Infection Control Preventionist (ICP) F regarding the facility policy in labeling personal items. The ICP reported that personal items should be labeled with resident identification. An observation was made in Resident #100 and #101's room with a urinal in the bathroom that was not labeled. The ICP indicated that the urinal should be labeled as well as the one at Resident #100's bedside. An observation was made with the ICP of the denture cup of Resident #37 stored under the towel dispenser near the sink in the room. The ICP indicated the cup should not be stored there and removed the denture cup from under the towel dispenser and indicated they would do education for the staff and the resident. An observation of Resident #28's urinal was observed to be at the Resident bedside. The Resident was sharing a bathroom with the Resident in the next room. The ICP indicated the urinal should be marked with identification and reported education would be provided to the staff.

Based on observation, interview and record review the facility failed to ensure medications were accurately administered for three residents (R4, R14, R25) of four residents reviewed for medication administration resulting in a medication error rate of 7.69%. Findings include: On 2/12/25 at 7:41am, Licensed Practical Nurse (LPN) 'C' prepared and administered medications for R25. The medications included: Acidophilus, Acetaminophen 500mg, pro-stat, Abilify 2mg, Buspar 5mg, Eliquis 5mg, Glipizide 10mg, Potassium Chloride 10mEq, Senna-S 8.6mg-50mg, Vitamin D 1000mcg, Metoprolol 100mg, Myrbetriq 25mg, Tamsulosin 0.4mg, Cymbalta 30mg, Lasix 40mg and Humalog 2units from an insulin pen. LPN 'C' prepared the insulin pens by dialing in the units to be administered to the resident. LPN 'C' did not prime the insulin pens prior to administering the prescribed units. On 2/12/25 at 8:02am, LPN 'C' prepared and administered medications for R4. The medications included: Novolog 7units from an insulin pen, Lantus 25units from an insulin pen, Amantadine 100mg, Chewable Aspirin 81mg, Gabapentin 100mg, Norvasc 5mg, Keppra 750mg, MagOx 400mg, Metformin 500mg, Myrbetriq 25mg, Senokot 8,6mg, Vesicare 10mg and Miralax 17gms in water. LPN 'C' prepared the insulin pens by dialing in the units to be administered to the resident. LPN 'C' did not prime the insulin pens prior to administering the prescribed units. On 2/12/25 at 8:15am, LPN 'C' prepared and administered medications for R14. The medications included: Gabapentin 400mg, Amlodipine 5mg, Fenofibrate 134mg, Fish Oil 1000mg, Hydrochlorothiazide 25mg, Metoprolol 25mg, Miralax 17gms in water, Multivitamin, Eliquis 5mg, Potassium 20 mEq, Flexeril 5mg, Vitamin D3 5000units, Tylenol Extra Strength 500mg and Lantus 40units in an insulin pen. LPN 'C prepared the insulin pen by dialing in the units to be administered to the resident. LPN 'C' did not prime the insulin pen prior to administering the prescribed units. On 02/12/25 at 11:08AM, an interview was conducted with the Director of Nursing (DON). The DON was asked how do you determine how much insulin to prime for insulin pens prior to dialing in the dosage for administration. The DON stated, we default to the manufacturers recommendation, our policy doesn't specify the amount of insulin to prime prior to administration. I usually prime the pen with 2 units prior to administration. On 02/12/25 at 11:12AM an interview was conducted with LPN 'C'. LPN 'C' was asked how much insulin should you prime in the insulin pen prior to administration. LPN 'C' stated they were not aware of having to prime the insulin pens. LPN 'C' stated they were just informed by other staff members that we are to prime 2 units in the pen before administering it. Record review of the policy titled, Injectable Medication Administration, revised January 2018, does not reference the amount of insulin to prime in the pen prior to administration.

This Citation pertains to Intake Number MI00147136. Based on interview and record review, the facility failed to hold a scheduled 72-hour care conference for one resident (R150) of one reviewed for care conferences, resulting in missing a care conference and lack of information for the family and resident. Findings include: Resident #150: R150 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include pneumonia, atrial fibrillation, chronic kidney disease and a malignant neoplasm of the bladder. R150 expired at the facility on [DATE]. R150 had a brief interview for mental status (BIMS score of 15, indicating they were cognitively intact. On [DATE] at 1:13PM, an interview was conducted with a confidential family member of R150. Family 'A' stated that a care conference was supposed to be held on Friday [DATE], Family 'A' wanted to join by phone and the facility said they would call her when it was time for the conference. Family 'A' stated that R150 eventually called them and said they never held the care conference on that day. Family 'A' said the care conference was completely omitted; we were ready for the conversation, but it just never happened. Family 'A' said they were told a time the conference would be held, and we were ready. Family 'A' stated she talked to R150 as well and R150 stated that the care conference never happened with her as well. On [DATE] at 11:32AM, an interview was conducted with Social Worker (SW) 'B'. SW 'B' was asked if they keep schedules for 72-hour care conferences. SW 'B' said that we schedule care conferences within 72hrs of admission. SW 'B' stated that another staff member schedules these care conferences, gives the family a card with the date and time and then lets us know. SW 'B' was asked when was R150 scheduled for a 72hr care conference. SW 'B' stated, I believe she was scheduled for [DATE], which was the day she passed away. SW 'B' then confirmed that R150 was scheduled on [DATE] at 7:30am for a care conference. SW 'B' verified with this surveyor that the meeting was set for [DATE]. SW 'B' was asked why the care conference wasn't held. SW 'B' stated, I don't know that answer, I truly don't know why it wasn't held. SW 'B' was asked what is discussed at the 72hr care conference. SW 'B' stated, we discuss the admission process, nursing is with us and they will review medications, dietary discusses diet, activities will discuss the activities in the facility and provide a calendar of events, and the director of therapy will discuss therapy's plan for the resident, we also discuss home evaluations for therapy and we discuss needs at home such as DME and home care. On [DATE] record review of the care conference calendar revealed that R150 had a care conference scheduled for [DATE] at 7:30am. Record review of the electronic medical record did not produce any record of the care conference being completed. Review of the policy titled, Resident/Family Participation- Assessment/Care Plans, revealed: 1. The resident and his/her family, and/or the legal representative (sponsor), are invited to attend and participate in the resident's assessment and care planning conference. 4. The social services director or designee is responsible for contacting the resident's family and for maintaining records of such notices. Notices include: a. The date of the conference, b. The time of the conference, c. The location of the conference, d. The name of each family member contacted, e. The date and time the family was contacted, f. The method of contacting the family (e.g. mail, telephone, email, etc.) g. Input from family members when they are not able to attend, h. Input from the resident when he/she is not able to attend, i. Refusal of participation, if applicable, and j. The date and signature for the individual making the contact.

Based on observation, interview and record review the facility failed to revise care plans for two residents (R19, R39) of a total sample of 17 residents, resulting in missing care plan updates and the potential for unmet needs. Findings include: Resident #19: R19 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include cerebral infarction, seizures, major depressive disorder and anxiety. R19 has a brief interview for mental status (BIMS) score of 5, indicating severe cognitive impairment. On [DATE] at 09:20AM, observation revealed that R19 is thin looking in appearance. On [DATE] at 03:19PM, record review of the electronic medical record (EMR) revealed R19's weight on [DATE] was 167.2lbs and on [DATE], R19's weight was 141.4lbs, this was a loss of 25.8lbs, 18% in 30 days. On [DATE] at 03:29PM, record review revealed that the care plan for nutrition didn't reflect weight loss until [DATE]. The last review of R19's nutrition care plan was [DATE]. Review of a dietary progress note indicates that the physician is aware of the weight loss, a physician note dated [DATE] addresses weight loss. On [DATE] at 12:13PM, an interview was conducted with Certified Dietary Manager (CDM) 'D'. CDM 'D' was asked who is responsible for updating the care plans for nutrition and weight loss. CDM 'D' stated that the dietitian and myself are responsible for that. CDM 'D was asked why the care plan wasn't updated until [DATE] when the first weight loss was identified back in [DATE]. CDM 'D' stated, I am not sure, but I will get back with you. CDM 'D' then said, ultimately it would be my responsibility to update the care plan along with the dietitian. Urinary Catheter or UTI: On [DATE] at 11:10AM, R19 was observed with an indwelling catheter in place. R19 states they have had their catheter for a long time, currently has a leg bag in place. On [DATE] at 01:57PM, record review of the physician's order for the indwelling catheter revealed it was an 18fr with 30cc balloon for neuromuscular dysfunction of the bladder, dated [DATE]. Record review revealed an order to change the catheter monthly on the 15th, order dated [DATE]. On [DATE] at 02:07PM, record review revealed a care plan in place for use of an indwelling catheter, the last update was [DATE] and states the catheter is a 16fr with 30cc balloon. On [DATE] at 02:23PM, an interview was conducted with the Director of Nursing (DON). The incorrect care plan was verified by the DON. The DON was asked who is responsible for updating care plans related to catheters. The DON stated that the infection control nurse is responsible for updating care plans for catheters. The DON was unsure why this care plan wasn't updated to reflect the correct catheter size. Resident #39: R39 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include acute respiratory failure, major depressive disorder, hypertension and chronic kidney disease. R39 has a BIMS score of 7 indicating severe cognitive impairment. On [DATE] at 09:37AM, record review revealed that R39 has a physician's order, dated [DATE] for do not resuscitate (DNR). Record review revealed signed documents for DNR, dated [DATE]. Record review revealed a care plan for advance directives that R39 was electing to be a full code and receive cardiopulmonary resuscitation (CPR), the care plan was updated on [DATE]. On [DATE] at 11:42AM, an interview was conducted with SW 'B'. SW 'B' was asked who is responsible for updating the care plan for code status. SW 'B' stated that whoever has the new order for code status, whether on admission or a change in status will update the care plan. SW 'B' stated I will update the care plan on admission if the documents are available and I know what the code status is. Verified with SW 'B that the advance directive care plan is not matching the physicians order or signed documents. Review of the policy titled, Care Plans- Comprehensive, revised [DATE], revealed: 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes.

Based on observation, interview and record review, the facility failed to ensure that Resident #13 received vision services and that recommendations were addressed for one resident (Resident #13) of one resident reviewed for vision services, resulting in the lack of follow-up care for vision issues and the potential for vision abnormalities to be untreated or unidentified. Findings include: Resident #13: A review of Resident #13's medical record revealed an admission into the facility on [DATE] and re-admission on 5/4/23 with diagnoses that included Parkinson's Disease, dementia, heart disease, high blood pressure and diabetes. A review of the Minimum Data Set assessment revealed the Resident had intact cognition with a Brief Interview for Mental Status score of 13/15. On 2/12/25 at 8:50 AM, the Resident was dressed, seated in a wheelchair in their room. The Resident was interviewed, answered questions and engaged in limited conversation. The Resident was asked about any concerns he had and stated, My eyes are really bad. When asked what was wrong with his eyes, he reported difficulty with seeing good. The Resident indicated he did not need to see the eye doctor about glasses but that he needed to see the eye doctor and had not seen the eye doctor for extended period of time. A review of Resident #13's medical record of the document titled Eye Care Group, revealed date of exam: 11/30/2023; history of cataract, nuclear; Pseudophakia. Assessment: 1. Diabetes Type 2, without complications, 2. Cataract, nuclear; Both eyes, 3. Dry eye; Both eyes. Plan: 1. Continue bs (blood sugar) control, 2. Cataract surgery not recommended due to poor general health, 3. Medication Order; Artificial tears oph. Solution, apply 1 drop, Both eyes, three times daily for 90 days. Action Required By Nursing Home Staff: Glasses Required? No; Eyelid Care Required: Yes BID x 90 days; New Orders? Yes (see plan above). Recall: 5-6 Months. A review of Resident #13's medical record of the document titled Eye Care Group, revealed date of exam: 4/12/2024. Note: Patient was scheduled to be treated today, but was not treated. Reason: Patient was Unavailable. Signed by the Optometrist. A review of Resident #13's medical record of the document titled Eye Care Group, revealed date of exam: 1/14/2025; history of cataract, nuclear; Diabetes Type 2, without complications; Dry eye; Pseudophakia. Assessment: 1. Diabetes Type 2, without complications, 2. Pseudophakia,3. Dry eye; Both eyes. Plan: 1. Monitor, 1. Continue bs (blood sugar) control, 2. Monitor, 3. Continue present eye medications, 3. Medication Order; Artificial tears oph. Solution, apply 1 drop, Both eyes, twice daily for 90 days. Action Required By Nursing Home Staff: Glasses Required? No; Eyelid Care Required: Yes BID x 90 days; New Orders? Yes (see plan above). Recall: 5-6 Months. A review of Resident #13's orders revealed no order in the month of January 2025 for the recommended eye drops in the plan for Artificial tears. A review of the progress notes revealed a lack of documentation on the recommendations of the Optometrist. A review of the progress notes revealed no documentation on why or where the Resident was on 4/12/24 when the Resident was not available to be seen by the Optometrist. On 2/12/25 on 12:58 PM, an interview was conducted with Nurse B who was the Social Worker Designee and the Scheduler/Medical Records E regrading Resident #13's appointments for eye care. The Scheduler was asked if Recall meant when the next appointment was to be made and she stated, Yes, that is there recommendation, of when to be seen again. A review of the Resident seen on 11/30/23 and next appointment was for 4/12/24, with the recommendation to be seen after the 11/30/23 appointment in the next 5 to 6 months, but the Resident was not available and had not been see by the eye care group until 1/14/25, was reviewed with Nurse B and Scheduler E. The Nurse was asked why or where the Resident was at when they were supposed to be seen by the eye care specialist. The Nurse and Scheduler indicated they did not know where the Resident was and indicated he could have been in activities or somewhere else in the building. A lack of documentation of where the Resident was and a lack of any interventions to try to assist in having the Resident available to be seen for eye care was reviewed. The Scheduler was asked if the eye doctor had come in prior to the January visit. The Scheduler returned and indicated the eye group had been back in October of 2024. When asked if the Resident was on the list to be seen, they indicated he had been on the list but were unsure why he had not been seen. The Scheduler reported prior to the end of the interview that the eye doctor had run out of time and was unable to see the resident. The Nurse and Scheduler were asked how soon the documents come back from the eye group. The Scheduler reported that the notes were back within 7 days, depending on the service and the doctor and the documents get uploaded into the electronic medical record. The recommendations for the eye drops had not been written for in the orders. When asked who gets the recommendations to get the orders into the medical record, the Nurse stated, I don't have an answer for that, will have to find out. On 2/12/25 at 3:29 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #13's lack of eye care after an appointment was missed due to the Resident not available, with lack of documentation of why or where the Resident was, and the Resident not seen when eye care had returned October 2024 with recommendations to be seen every 5-6 months. The DON indicated that they don't know that the Resident was not seen until they get the communication form. When asked why the order for the eye drops, Artificial tears, apply 1 drop, both eyes, three times daily for 90 days, the DON reported that the eye doctor puts that for all his patients that he sees. It was reviewed with the DON of a lack of documentation regarding why the recommendation was not followed and if the Resident did not need them. A policy for Vision care was requested on 2/13/25 but was not provided by the facility prior to exit. A review of facility document titled Treatment Consent Form, revealed, .We offer a variety of services for our residents that will benefit their quality of life. Dental, Vision, and Podiatry consultation . services are available and will be provided as needed, if you choose .

Based on observation, interview and record review, the facility failed to ensure that Infection Prevention and Control standards of practice were followed for 1) Transmission Based Precautions, Hand Hygiene and Central Venous Catheter care for 1 resident (Resident #97), 2) Personal Protective Equipment (PPE) use during medication administration, and 3) Management of soiled and clean linen, resulting in the potential for spread of infection, which could cause serious illness. Findings Include: On 2/20/2024 at 10:46 AM, during a tour of the facility, Resident #97 was observed lying in bed, awake and alert; He readily answered questions. The resident said he was at the facility because he had sores on his left shoulder and bottom. An IV pole was near the bed and the resident said he was receiving IV antibiotics. The resident lifted his right arm and showed that he had a PICC (Peripherally Inserted Central Line) IV for his antibiotic therapy. A record review of the Face sheet indicated Resident #97 was admitted to the facility on [DATE] with diagnoses: Pressure ulcer left upper back(shoulder) Stage 3, Pressure ulcer sacral region Stage 2 (infected with a multi-drug resistant organism/MDRO), urine infection with an MDRO, left and right above the knee amputations, peripheral vascular disease, diabetes, urine retention, high blood pressure, anxiety, depression, obesity and gastric reflux. On 2/21/2024 at 10:45 AM, a sign was observed on Resident #97's door, Stop: See Nurse before entering. There was no additional information. This sign was not present on 10/20/2024 at 10:46 AM during the initial tour. On 2/21/2024 at 10:48 AM, Infection Control/IC Nurse C was interviewed in front of the door to Resident #97's room. She said she was on vacation when the resident came in 2/6//2024 and he was receiving IV antibiotics for MRSA (Methicillin Resistant Staphylococcus Aureus- an MDRO) in a shoulder wound and an ESBL (Extended spectrum bet-lactamase producing organism/an MDRO) in the urine. The IC Nurse said Resident #97 should have been placed in Contact Precautions on admission (2/6/2024). She said a sign should have been on the door and PPE was supposed to be worn with dressing changes and care of the Foley catheter. The PPE was observed to be in the resident room, she said it was in there because it only needed to be worn when providing the wound care/Foley care. No sign was observed indicating Contact Precautions were required. CDC: Centers for Disease Control and Prevention: Transmission-Based Precautions, Last reviewed July 11, 2023, Contact Precautions: Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission . Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens . On 2/21/24 at 2:20 PM, wound care for Resident #97 was observed with Nurse E and two nursing assistants. The resident had 3 wounds on the buttocks/sacral area: one small, one larger approximately 4 cm x 1 cm and one very large approximately 9 cm x 3.5 cm. The wounds were bleeding, the largest wound was bright red, with a moderate amount of blood. There were also 2 wounds on the resident's left shoulder one small about 0.5 cm x 1.0 cm and the other very large open with a packed dressing/gauze in place approximately 8 cm x 7 cm. The nurse removed the old dressings, removed her soiled and gloves and donned new gloves. She did not perform hand hygiene. Nurse E then cleansed the shoulder wound, packed the wound and applied new dressings. The nurse removed her soiled gloves and immediately opened several alcohol pads and started cleaning her bandage scissors bare handed. She did not perform hand hygiene. The nurse did not perform hand hygiene until she was done cleaning up the supplies with her bare hands. Reviewed hand hygiene with the nurse, she stated, Oh, I didn't wash my hands. The resident's wounds were infected with an MDRO. CDC: Centers for Disease Control and Prevention, Last reviewed January 8, 2021, Healthcare Providers: Clean hands count for Healthcare Providers: Protect yourself and your patients from potentially deadly germs by cleaning your hands. Be sure you clean your hands the right way at the right times . Glove Use: . If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment; Perform hand hygiene immediately after removing gloves . On 2/21/2024 at 2:55 PM, Nurse E was observed during administration of the IV antibiotic for Resident #97. The resident was receiving the antibiotic because he had 2 different Multi-drug Resistant Organisms (infections): one in a wound and the other in his urine. The resident was in Contact Precautions per the IC Nurse and gloves and gown were to be worn. The nurse did not wear gloves during administration of the IV antibiotic. Nurse E cleansed the IV port with her bare hands while holding a small alcohol pad (approximately 1 in x 1 inch). She did not let it the alcohol dry and immediately flushed the IV catheter with a saline syringe. The Nurse swabbed the IV port with another alcohol pad while holding it with bare hands and connected the IV tubing containing the IV antibiotic. She did not let the alcohol dry after cleansing the port, prior to connecting the IV tubing. A review of the policy titled, Medication Administration, dated 01/23 provided, Medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices . APIC (Association for Professionals in Infection Control and Epidemiology), APIC Implementation Guide: Guide to Preventing Central Line-Associated Bloodstream Infections, dated 2015, . APIC Implementation Guides help infection preventionists apply current scientific knowledge and best practices to achieve targeted outcomes and enhance patient safety . Central venous catheters (CVC) or central venous access devices (CVAD's), often described by healthcare professionals as central lines, refer to a broad category of invasive devises used to administer fluids, medications, blood and blood products and parenteral nutrition . these central devices access major vessels that are most often located in the neck or adjacent to the heart . There are four general categories of CVAD's: non-tunneled (e.g., access via subclavian or internal jugular veins); peripherally inserted central catheters (PICC's) inserted via peripheral veins .; subcutaneously tunneled; and implanted vascular access ports . Central lines are a major risk factor for bloodstream infection . Research indicates that a majority of CLABSI's are preventable . Aseptic technique with all catheter access procedures . Failure to disinfect the needleless connector before accessing has been an important problem and area of concern. The catheter hub and needleless connector are known sources of microbial contamination . On 2/22/24 at 10:09 AM, IC Nurse C was interviewed about the observations during wound care and IV administration for Resident #97, she said she had heard about both and said the Nurses were trained in proper procedures and the nurse should have performed hand hygiene after removing her gloves and should wear gloves when disinfecting equipment, accessing the PICC line and cleansing the IV hub. She said she should have let the alcohol dry on the IV hub before accessing it. 39059 Medication Administration Task On 2/21/24, at 8:31 AM, During medication administration task, Nurse E prepared medications for Resident #27. Nurse E grabbed a pair of gloves from the medication cart, placed them into their left pocket of their scrub bottoms, gathered the medications and entered the residents room. Nurse E offered the oral medications, pulled out the gloves from their pocket and put them on. Nurse E then administered the nasal medication. Nurse E left out of the room and was asked why they used gloves from their pocket and Nurse E stated, it's easier to just grab them. Nurse E' was asked if the facility provided enough PPE (personal protective equipment) and Nurse E stated, yes, it's so I didn't have to get them from the room. 39083 On 2/21/24 at 11:07 AM, during an observation of the laundry facilities, a specific designated soiled linen area was observed to be unavailable to prevent contamination of clean linens. Four soiled linen carts, containing bagged and unbagged soiled linen, were observed to be surrounding the washers. At this time, Laundry Director (LD) I was queried on how they keep soiled linen separate from clean linen and she stated that they bring in the yellow clean cart from the dryer room to unload clean linen from the washers. An aisle in front of the washers was observed to be wide enough to accommodate for the clean linen cart, while it is sitting approximately 6 inches away from the soiled linen cart. No covers were observed on the soiled linen carts at this time and soiled laundry was observed to be hanging over the edge of the soiled linen cart toward the aisle in front of the washers. Additionally, the soiled linen carts to the right of the washers were observed to be blocking the hand washing sink. LD I was queried on the blocked hand sink and stated they can move the carts around to access the handwashing sink. During an interview on 2/21/24 at 12:38 PM, Corporate Consultant K stated that laundry processing is brand new to the facility as it used to be outsourced and the staff are still working on the new process. At this time, Corporate Consultant K stated that they will purchase new covers for the soiled linen carts and make adjustments to allow for more separation of clean and soiled linens. During an interview on 2/21/24 at 1:31 PM, Corporate Consultant K stated that they will reduce the number of soiled linen carts in the washer room and make plumbing adjustments to make the handwashing sink more accessible.

Based on observation and interview, the facility failed to maintain the ambient air temperature at a comfortable level, resulting in the potential for uncomfortable living conditions and a non-homelike environment, affecting resident's rooms (#'106, #104, #105, #101 and #203). Findings include: On 2/21/24 at 1:43 PM, Resident #11 was observed to be voicing a complaint to staff regarding their room being too hot. At this time, using an infrared thermometer, the hall outside of the resident's room was observed to be 81.1 degrees F. On 2/21/24 at 1:45 PM, the bathroom of room [ROOM NUMBER] was observed to be 86.0 degrees F. During an interview on 2/21/24 at 1:46 PM, Resident #11 stated that it is hot in their room and if they don't have a fan, they aren't able to sleep at night. Resident #11 continued to say that they talked to maintenance, and they tried to fix it a few months ago but they haven't heard anything else about it. Using an infrared thermometer, the residents bed area was observed to be 85.0 degrees F. On 2/21/24 at 2:10 PM, room [ROOM NUMBER] was observed to be 88 degrees F. On 2/21/24 at 2:11 PM, room [ROOM NUMBER] was observed to be 93 degrees near bed A. Resident #1, in bed A, has a diagnosis of Alzheimer's and a BIMS score of 0. Resident #13 in bed B has a diagnosis of Dementia and a BIMS score of 6. At this time, Resident #1 was asked how they were doing and did not reply. On 2/21/24 at 2:15 PM, Resident #297 stated that it is really hot in their room and could use some air conditioning. At this time, the area around Resident #297's bed was observed to be 83.3 degrees F, using an infrared thermometer. During an interview on 2/21/24 at 2:40 PM, Maintenance Director J was queried regarding the high temperatures and stated they are adjusting the temperatures to try to cool down the rooms. The Facility utilizes a floor heating system, and they are waiting for some parts/valves that need replacing. Maintenance Director J continued to say that the repair process began on January 18th, and they are hoping to get the parts in on Friday 2/23/24.

Based on observation, interview and record review, the facility failed to ensure supervision, call light accessibility and document an unassisted transfer for one resident (Resident #36), resulting in the likelihood of an injury and/or a fall and continued self-transfers going unassessed. Findings include: Resident #36: On 2/20/24, at 3:49 PM, Resident #36 was sitting in their wheelchair next to their bed. The foot pedals were hooked to the wheelchair. Resident #36 put their feet on the floor and was attempting to stand up. CNA G was asked if Resident #36 was able to get up on their own and CNA G stated, no, but tries to and we catch her. She's a sneaky one. On 2/21/24, at 9:30 AM, a record review of Resident #36's electronic medical record revealed an admission on 10/01/2023 with diagnoses that included CVA (Stroke affecting left dominant side), Aphasia and Multiple Sclerosis. A review of the most recent Minimal Data Set assessment revealed Resident #36 had severely impaired cognition and required extensive assistance with Activities of Daily Living (ADL's). A review of the care plan I have an actual ADL deficit R/T: (related to) recent CVA with left sided weakness. Multiple sclerosis . Date Initiated: 10/01/2023 . Interventions/Tasks Do not leave resident unattended in the bathroom Date Initiated: 11/10/2023 . A review of the care plan Risk for falls f/t left sided weakness, recent CVA Date Initiated: 10/01/2023 . Interventions . Call light accessible . A review of the care plan COGNITION: I am overall alert, however I need extra time to process and respond. I demonstrate short term memory deficits with impaired judgement r/t my dx (diagnosis) of Dementia. BIMS=7. Date Initiated: 10/03/2023 . Goal Resident will be comfortable safe and have needs met . Interventions . Anticipate Needs. Date Initiated: 10/03/2023 . On 2/21/24, at 1:51, an observation of Resident #36 overheard yelling Help me, Help from their bathroom. Entered Resident #36's room to find Resident #36 in their bathroom on the toilet. Their wheelchair was pushed straight forward into the wall. The wheelchair breaks were not engaged. Resident #36 attempted to pull the emergency call light on the wall. The resident lifted the string with their right hand and pulled in outward motion. The call light did not engage. From the resident's doorway into the hallway, three staff members were observed near the medication cart two rooms down in the hallway. The nurse stated she had medications in their hands and the two CNAs were asked for help. Infection Control Nurse C entered Resident #36's room and CNA F entered the bathroom and stated she was just in the activity as they applied a gait belt. Resident #36 stated, I'm sorry I had to go potty. Once CNA F assisted the resident to their wheelchair, Resident #36 was facing the call light and was able to engage the call light with both hands by pulling down on the call light string. A further record review of Resident #36's electronic medical record revealed no documentation of the resident noted in the bathroom on their own.

Based on observation, interview and record review, the facility failed to provide Nystatin (oral antifungal medication) timely for one resident (Resident #297), resulting in delayed treatment with the likelihood of continued infection and/or a return of the infection. Findings include: Resident #297: On 2/20/24, at 11:40 AM, during medication administration task, Nurse H prepared medications for Resident #297. Nurse H looked in the medication cart for the Nystatin medication. Nurse H was unable to locate the Nystatin. Nurse H was asked where the medication could be and Nurse H reviewed the order form in the electronic medical record which revealed On Order and stated, it should be here by 3:00 PM today. On 2/21/24, at 11:00 AM, a record review of Resident #297's electronic medical record revealed an admission on 2/19/2024 with diagnoses that included Recurrent lung cancer, recent Acute Respiratory Failure and Hypertension. Resident #297 had intact cognition and required assistance with Activities of Daily Living. A review of the Physician orders revealed Nystatin Mouth/Throat Suspension 10000 UNIT/ML . Medication Class: ANTIFUNGALS . Created Date: 2/19/2024 18:59 (6:59 PM) . Signed Date: 2/20/2024 04:20 (4:20 AM) A review of the Medication Administration Record February 2024 revealed Tue 20 0600 1200 both times were marked OS (Other/See Nurses Notes. A review of the Nurse Notes revealed the following missed Nystatin doses: 2/19/2024 22:05 (8:05 PM) Note Text: Nystatin Mouth/Throat Suspension . Give 5 ml (milliliters) by mouth every 6 hours . for 3 days Pharmacy to deliver, not in E-kit. 2/20/2024 05:01 (5:01 AM) Note Text: Nystatin Mouth/Throat Suspension . Pharmacy to deliver, not in E-kit. 2/20/2024 11:40 (11:40 AM) Note Text: Nystatin Mouth/Throat Suspension . Not available, on order. There was no documentation notifying the physician of the three missed Nystatin doses. On 2/22/24, at 12:38 PM, Resident #297 was in their room and stated their mouth still hurt but wasn't as bad as when they were in the hospital. On 2/22/24 at 2:18 PM, Infection Control Nurse (IC) C was asked was asked why Resident #297's Nystatin was not given as ordered and IC Nurse C stated, it didn't come from the pharmacy and the e-kit (backup medication) was a different dose. IC Nurse C was alerted there was no note notifying the physician and possibly getting the dose changed and IC Nurse C stated, there will be an education given to the nurse.

Based on observation, interview and record review, the facility failed to ensure that narcotic storage for the East Medication Cart and narcotic reconciliation was completed legibly for East and [NAME] Medication Carts, resulting in scribbled numbers, unsafe narcotic storage with the likelihood of misappropriation going unnoticed. Findings include: On 2/21/24, at 8:31 AM, During medication administration task, Nurse E prepared medications for Resident #27. Nurse E opened up the bottom drawer and lifted up the narcotic drawer lid which was not locked. Nurse E removed 1 dose of Adderall medication, replaced the pack of Adderall and closed the narcotic drawer lid without engaging the lock. Nurse E closed the bottom drawer gathered the medications and provided them to the resident. Once Nurse E returned to the medication cart, Nurse E opened up the bottom drawer and was asked to open the narcotic drawer lid. The lid was not locked. Nurse E was asked why the narcotic drawer lid was not locked and Nurse E stated, we lock in every time with the medication cart but I'm not used to an audience. Nurse E was asked if the lock was broken and Nurse E pulled out their keys and locked the narcotic drawer lid with their keys. A record review of the CONTROLLED MEDICATIONS SHIFT CHANGE SIGN OUT SHEET along with Nurse E was conducted. For the date, 2/21/24 6 AM NUMBER REC'D (RECEIVED) FROM PHARMACY . There was a number 1 with a number 2 written over top. For the column NUMBER OF FULL CASSETTES It appeared it was a 14 with a 7 or a 2 written over top. For the column, NUMBER OF PARTIAL CASSETTES . There was a 25 with a 7 written over top of the number 5. Nurse E was asked if there was a discrepancy during Narcotic Reconciliation at shift change and Nurse E stated, we had to double check the total number but no to a discrepancy. Nurse E denied alerting the Director of Nursing (DON). On 2/22/24, at 12:12 PM, A record review along with the Director of Nursing (DON) was conducted of the west medication CONTROLLED MEDICATIONS SHIFT CHANGE SIGN OUT SHEET which revealed 2/22/24 . NUMBER REC'D FROM PHARMACY . There was + 5 written over top of a 4 or a 1. For the column, NUMBER OF EMPTY D/C (DISCONTINUE) CONTAINERS RETURNED TO DON revealed a 0 with a 2 written over top or vice versa with a 1 written under the column on the form. For the date 2/14/24 3 AM revealed NUMBER OF FULL CASSETTES revealed a 9 8 both lined out with a 7 written in the column. For the column, NUMBER OF PARTIAL CASSETTES revealed + 6 or 16 with a line crossed through with a 7 written to the right. The DON was asked how often they review the narcotic reconciliation medications shift change sign out sheet's and the DON stated, monthly and further offered they are not supposed to do that. A review of the facility provided Medication Storage 01/23 revealed . Controlled medications should be stored separately from non-controlled medications (see state regulations for CIII-V). The access system (key, security codes) used to lock Schedule II medications and other medications subject to abuse, cannot be the same access system used to obtain the non-scheduled medications. Schedule II medications and preparations must be stored in a separately locked permanently affixed compartment .

Based on interview and record review, the facility failed to provide documentation of adequate notice of Medicare Part A benefits of non-coverage for one resident (Resident # 296) of three residents reviewed for notice of non-coverage of Medicare Part A benefits, resulting in the resident's inability to exercise the right to file an appeal in a timely manner. Findings include: During a review of the Notice of non-coverage for Medicare part A benefits on 2/21/2024 at 10:30 AM, the facility provided a document titled, Beneficiary Notice- Residents discharged Within the Last Six Months. The form revealed Resident #296 was discharged to Home/Lesser Care on 9/6/2023. On 2/21/2024 at 10:40 AM, during an interview with Accounts Coordinator A, she said (Resident #296) did not have a Notice of Medicare Non-Coverage form. She provided an Active Discharge Planning Note dated 9/5/2023 that said the resident's LCD/Last covered day, was 9/5/2023 and the resident was to be discharged home on 9/6/2023. The note said, Resident and family aware. When asked who was responsible for providing the Notice of Medicare Non-Coverage form to the residents or their representatives that included information to inform them of their rights to appeal the decision, the Accounts Coordinator A said it was either herself or the Director of Nursing. On 2/22/2024 at 9:20 AM, the Director of Nursing/DON was interviewed about the discharge from Medicare Part-A skilled coverage, she said she could not find the NOMNC (Notice of Medicare Non-Coverage) form for the resident. She said it was not in the resident's medical record and she could not find it elsewhere. There was no documentation that the resident received appropriate notification that Medicare Part A Services were ending. No policy was received related to notification of Medicare A completion of services.

Based on interview and record review the facility failed to complete Minimum Data Set (MDS) assessments timely for two residents (Resident #13, Resident #97) of 19 sampled for MDS assessments, resulting in late annual and admission MDS assessments. Findings include: Resident #13: On 02/20/24 record review revealed that resident #13 is [AGE] years old, was readmitted on [DATE] with diagnoses of hypertension(high blood pressure) gastroesphoageal reflux disease (heartburn), neurogenic bladder, stroke, dementia, anxiety and depression. On 02/21/24 at 04:10 PM, record review revealed an MDS assessment dated [DATE] Annual None PPS that was due by 2/21/24. On 02/22/24 at 08:05 AM, record review revealed the same MDS assessment dated [DATE] Annual None PPS that was due by 2/21/24 and was currently not completed. On 02/22/24 at 01:30 PM, record review revealed an MDS assessment dated [DATE] Annual None PPS was showing that the MDS assessment was completed on 2/20/24. Review of Section M revealed that answers from the DON were locked on 2/22/24 at 11:45 AM. On 02/22/24 at 01:45 PM the Director of Nursing (DON) was interviewed and asked when an MDS admission assessment should be completed and they stated the assessment should be completed in 14 days from the admitted . The DON was also asked about the timing of the locked answers in Section M for resident #13 and if that meant the MDS was completed late and they replied yes. On 02/22/24 review of the Center for Medicare and Medicaid Services website revealed that the MDS is a standardized assessment tool that measures health status in nursing home residents. MDS is an extremely valuable resource for studying function and disability on a large scale in vulnerable older adults. 37666 Resident #97: On 2/20/2024 at 10:46 AM, during a tour of the facility, Resident #97 was observed lying in bed, awake and alert; He readily answered questions. The resident said he was at the facility because he had sores on his left shoulder and bottom. An IV pole was near the bed and the resident said he was receiving IV antibiotics. The resident said he needed assistance with most of his care including turning and repositioning. He said that was why he had the infected wounds, because when he was home, he didn't have assistance. He said he had a lot of phantom pain from having both lower legs amputated, and it hurt to reposition. A record review of the Face sheet indicated Resident #97 was admitted to the facility on [DATE] with diagnoses: Pressure ulcer left upper back(shoulder) Stage 3, Pressure ulcer sacral region Stage 2 (infected with a multi-drug resistant organism/MDRO), urine infection with an MDRO, left and right above the knee amputations, peripheral vascular disease, diabetes, urine retention, high blood pressure, anxiety, depression, obesity and gastric reflux. On 2/20/2024 at 2:30 PM, a record review of the Minimum Data Set/MDS assessment indicated it was to be completed by 2/19/2024 to aid in developing a plan of care to assist the resident with his care needs and goals. The MDS was not completed by 2/20/2024. A record review on 2/21/2024 at 4:00 PM, indicated the Admission MDS assessment for Resident #97 was still incomplete. On 2/22/2024 at 1:50 PM, during an interview with the Director of Nursing, she said she was responsible for completion of the MDS assessments. When asked when the Admission MDS for Resident #97 was due for completion, she said it was due on 2/19/2024. She said it was completed on 2/21/2024. When asked if it was late, she stated, Yes.

Based on interview and record review the facility failed to ensure that transmitted quarterly Minimum Data Set (MDS) assessments were accepted for four residents (Resident #18, Resident #26, Resident #27, Resident #33) of 19 residents sampled for MDS concerns resulting in quarterly MDS assessments being rejected. Findings include:, On 02/22/24 at 01:50 PM the Director of Nursing (DON) was interviewed about why some MDS assessment from 10/18/23 were showing as rejected, the DON replied that there was an issue with Section O of the MDS from October and that is why they were rejected. When asked if anyone was aware of the assessments being rejected the DON replied that a corporate office person usually audits to ensure that assessments were accepted and they must have missed these assessments. Resident #18: On 02/22/24 record review revealed that Resident #18 is [AGE] years old and was admitted on [DATE] with diagnoses of hypertension (high blood pressure), diabetes, hyperlipidemia (high cholesterol), stroke, dementia and chronic obstructive pulmonary disease (COPD). On 02/22/24 record review revealed an MDS assessment for resident #18 dated 10/18/23 that was exported but rejected. Resident #26: On 02/22/24 record review revealed that resident #26 is [AGE] years old and was admitted on [DATE] with diagnoses of atrial fibrillation, coronary artery disease, hypertension (high blood pressure), hyperlipidemia (high cholesterol), Alzheimer, anxiety, depression and psychotic disorder. On 02/22/24 record review revealed an MDS assessment for resident #26 dated 10/18/23 that was exported but rejected. Resident #27: On 02/22/24 record review revealed that resident #27 is [AGE] years old and was admitted on [DATE] with diagnoses of anemia, heart failure, hypertension (high blood pressure), diabetes, hyperlipidemia (high cholesterol), seizure disorder, depression and chronic obstructive pulmonary disease (COPD). On 02/22/24 record review revealed an MDS assessment for resident #27 dated 10/18/23 that was exported but rejected. Resident #33: On 02/22/24 record review revealed that resident #33 is [AGE] years old and was admitted on [DATE] with diagnoses of coronary artery disease, heart failure, hypertension (high blood pressure), dementia, Parkinson, anxiety, depression and schizophrenia. On 02/22/24 record review revealed an MDS assessment for resident #33 dated 10/18/23 that was exported but rejected. On 02/22/24 review of the Center for Medicare and Medicaid Services website revealed that the MDS is a standardized assessment tool that measures health status in nursing home residents. MDS is an extremely valuable resource for studying function and disability on a large scale in vulnerable older adults.

Based on observation, interview and record review, the facility failed to follow the care plan, assess and monitor blood pressure and the heartrate (pulse) for one resident (Resident #31, resulting in unassessed vital signs with the likelihood of blood pressure or pulse changes going unnoticed. Findings include: Resident #31: On 2/21/24, at 2:45 PM, a record review of Resident #31's electronic medical record revealed an admission on 08/11/2023 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), Anemia and Diabetes. Resident #31 had intact cognition and required assistance with Activities of Daily Living. A review of the care plan actual alteration in oxygen exchange r/t COPD Date Initiated: 08/11/2023 Goal Resident will be free of respiratory distress Date Initiated: 08/11/2023 . Observe for s/sx (signs and symptoms) of respiratory distress and report to MD PRN (as needed): Abnormal respiratory rate, pulse ox, increased heart rate . A review of the vitals section revealed the resident hadn't had a blood pressure assessed since 11/11/2023 and their last heartrate check was on 12/25/2023. A review of the physician progress notes revealed Effective Date 2/7/2024 . She is a patient who has medical diagnoses currently of a recent UTI with overactive bladder, sciatica, anemia, COPD, diabetes, hypertension, sleep apnea, gastroesophageal disease with depression, dyslipidemia and alcohol abuse . The patient also has history of hypertension and believes that for most part the blood pressure are stable. She however sometimes forgets to check it on a regular basis . EXAM Vitals reviewed . COPD. She continues to have some symptoms of shortness of breath with activity and exertion on account of her COPD. She does have some minimal wheezing also . On 2/22/2024, at 10:30 AM, Resident #31 was asked if they had their blood pressure checked and Resident #31 stated, they just did it this morning.

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure comprehensive analysis of falls, accurate documentation, and implementation of meaningful fall prevention interventions for two residents (Resident #2 and Resident #11) of four residents reviewed, resulting in a lack of root cause analysis of falls, inaccurate and incomplete documentation, and a lack of implementation of meaningful interventions following falls. Resident #11 suffered a left shoulder dislocation, fractured the greater tuberosity (head of the humerus bone which rotates in the shoulder joint), and suffered unnecessary pain and the loss of function. Findings include: Resident #2: On 1/19/23 at 10:04 AM, an observation occurred of Resident #2 in their room. The Resident's room was noted to be at the end of the hallway and the furthest from the nurses' station. The Resident was aimlessly wandering within the room independently. When spoke to, Resident #2 made unintelligible grunting sounds. On 1/19/23 at 10:50 AM, loud, indiscernible yelling was heard in the hallway of the facility. Upon inspection, Resident #2 was observed in their room yelling. When asked if they needed anything, Resident #2 stopped yelling but did not respond. The Resident immediately began yelling out again. Record review revealed Resident #2 was originally admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, anxiety, schizophrenia, osteoporosis, and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required extensive, one-person assistance for bathing but was independent with all other Activities of Daily Living (ADL's). The MDS further revealed the Resident displayed behaviors daily both directed and not directed towards others. On 1/20/23 at 2:03 PM, Resident #2 was observed ambulating independently in their room. The Resident repeatedly walked to the doorway, stopped, and then walked back to their bed. The Resident did not respond when spoke to. Review of documentation in Resident #2's Electronic Medical Record (EMR) revealed the following assessments: - 9/16/22: Falls Assessment . History of falls . Location of the fall . medications . Antipsychotics . Antidepressants . Cardiovascular . Fall risk assessed for quarterly assessment, resident remains at risk for falls r/t medications and poor safety awareness . - 1/3/23: Falls Assessment . medications . Antipsychotics . Antidepressants . Cardiovascular . Fall risk assessed for quarterly MDS. Resident at low risk for falls r/t medications and cognition. Resident remains independent for ambulation and ADL's . - 1/14/23 at 12:14 AM: Falls Assessment . Fall Review . Resident was observed on floor in bedroom at foot of bed sitting on bottom wearing only a brief. No footwear in place. Call light not in use. Resident is unable to give description of what happened. Nurse assessed resident for injuries, ROM (Range of Motion), vitals, pain WNL (Within Normal Limits). Resident did have abrasion/discoloration to abdomen extending up to armpit where it appears they slid down the footboard of bed. Resident was incontinent of bladder at time of incident . usually independent for toileting. Resident was assisted from floor and assisted with cleaning up, then back to bed. Care plan was reviewed and updated to encourage resident to wear nonslip footwear while out of bed as allows . IDT (Interdisciplinary Team) met to review resident, care plan was reviewed and updated . Review of Resident #2's care plans included a care plan entitled, SAFETY: risk for falls r/t (related to) hx (history) of falls, medications, cardiac diagnosis, osteoporosis, osteoarthritis, schizophrenia, Alzheimer's disease. recent falls (Created and Initiated: 4/22/17; Revised: 11/4/17). The care plan included the following interventions: - I will wear non-skid footwear for all transfers and walking (Created and Initiated: 4/22/17) - Encourage resident to use nonskid footwear when out of bed as tolerated (Initiated: 1/14/22; Created: 1/17/23) - Unused chair removed from resident's room to reduce trip hazard (Created and Initiated: 7/22/20) - Orient to surroundings - Call light accessible (Created and Initiated: 2/18/20) Review of Resident #2's progress note documentation in the EMR detailed: - 1/13/23 at 11:20 PM: Nurses Note . Resident observed on floor at foot of bed by CAN (Certified Nursing Assistant). Upon observation, resident sitting on buttocks on floor wearing only a brief. Resident independently transferred from bed attempting to self-toilet at approximately 2320 (11:20 PM). Neuro checks initiated . Resident observed with discoloration noted on chest that extended down onto ABD (abdomen), discoloration to left upper arm near elbow, and discoloration to right wrist. Resident without any indication of pain at time of assessment. Resident incontinent of bladder at time of fall. On call NP (Nurse Practitioner) notified . Voicemail left with guardian . Will update CP (care plan) to encourage use of nonslip footwear when out of bed. - 1/14/23 at 12:33 AM: Incident Note . Resident unable to follow commands to observe hand grasps. Resident observed grasping edge of bed to pull self-up along with grasping sheets to cover self. - 1/16/23 at 8:52 AM: Incident Note . No s/s of pain or bruising noted due to recent fall . No additional documentation related to the bruising/abrasions documented following Resident #2's fall on 1/13/23 were noted in the EMR. Review of the facility provided Incident and Accident Report related to the Resident #2's fall revealed, Fall . 1/13/23 at 23:30 (11:30 PM) . Called into room by CNA to observe Resident sitting on floor in brief at end of bed near footboard. Call light not in use. Feet bare . Resident unable to give description . Injuries observed Abrasion: Abdomen . Other, Specify in Notes . Mental Status: Poor Safety Awareness . Notes: Abrasions noted to chest extending to Abd, LUE (Left Upper Extremity) near armpit and right wrist Injuries Report Post Incident: No injuries observed post incident . Predisposing Physiological Factors: Gait Imbalance .Predisposing Situation Factors: During transfer . Footwear not in place . On 1/24/23 at 10:46 AM, an interview was completed with CNA A. When queried if Resident #2 responds verbally and talks to them, CNA A replied, No, not really. I think it is part of their disease process. When asked if the Resident utilizes the call light, CNA A indicated they did not. An interview was conducted with Resident Care Coordinator Licensed Practical Nurse (LPN) B on 1/24/23 at 2:00 PM. When queried regarding Resident #2 not responding when asked questions and yelling out, LPN B revealed that was normal for the Resident. When queried regarding the Resident's fall on 1/13/23, LPN B indicated they were not working at the time. An interview was conducted with the Director of Nursing (DON) on 1/25/23 at 11:30 AM pertaining to Resident #2's fall on 1/13/23. When queried if the only intervention implemented following the fall was to encourage the Resident to use non-slip footwear when out of bed, the DON reviewed the Resident's EMR and revealed it was. When queried regarding Resident #2 already having an intervention on their care plan for non-slip footwear when that intervention was added and how added the same intervention would help to prevent future falls, the DON verbalized understanding. When queried regarding the documented skin abrasions/bruises documented at the time of the fall and facility policy/procedure for monitoring skin alterations following a fall, the DON indicated there should be documentation in the nursing progress notes. The DON reviewed Resident #2's EMR and indicated the areas were resolved per the note on 1/16/23. No further information was provided. Resident #11: On 1/19/23 at 10:40 AM, Maintenance Director C was observed in Resident #11's room placing a positioning device on the footrest of their wheelchair. An interview was completed with Resident #11 on 1/19/23 at 10:42 AM following Director C exiting the room. Resident #11 observed was sitting in a regular wheelchair with bilateral leg rests in place. A padded positioning device was present on the right footrest. When asked, Resident #11 revealed Director C had placed the positioning device on the footrest of their chair. Resident #11 was queried regarding the reason for having a padded position device on only one footrest and revealed it was due to pain. Resident #11 stated, I fell and hurt my feet and left shoulder. When queried regarding the fall, Resident #11 revealed they fell at the facility and broke their shoulder. When asked if they had recovered from the fracture, Resident #11 revealed they had pain and decreased ROM following the fall. When asked if they were able to move their left shoulder, Resident #11 lifted their arm from their lap forward and to their side less than 90 degrees. Record review revealed Resident #11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epilepsy, falls, schizophrenia, and greater tuberosity of left humerus fracture. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively intact and required extensive to total assistance to complete all ADL's with the exception of eating. The MDS further revealed the Resident had one-sided, impaired upper extremity Range of Motion (ROM). Review of prior MDS assessment documentation of Resident #11's Functional Limitation in ROM revealed Resident #11 had no ROM limitations in any extremity until 8/31/22. Review of the CMS-672 Resident Census and Condition Form revealed the facility had three Residents with contractures including one facility-acquired contracture. The DON was queried regarding the Residents with contractures including the facility-acquired contracture on 1/19/23. The DON replied via email on 1/19/23 at 4:24 PM and revealed Resident #11 had a facility-acquired contracture. Review of Resident #11's EMR revealed the following documentation: - 2/23/22 at 10:35 AM: eInteract Change in Condition Evaluation . Falls . Skin Evaluation . Face: Laceration . Chest: Abrasion . Pain (rating not documented) . Pain Location: Not applicable/Not assessed . - 2/24/22 at 11:08 AM: Nurses Note . Abrasion to forehead shows no sign of infection. - 2/25/22 at 12:33 AM: Incident Note . Resident skin tear above eye area well approximated with no s/sx (signs/symptoms) of infection or swelling noted or reported. - 2/25/22 at 8:22 AM: Incident Note . Resident with skin tear above eyebrow with no s/s of infection noted. Goose egg to forehead has decreased with bruising to area. Resident with bruising and scrap (sic) to right side and up under breast. - 2/25/22 at 6:21 PM: Nurses Note . resident alert and easy to arouse . no injuries, bruising, skin intact. Resident with no s/sx (signs/symptoms) of pain or discomfort post fall . -2/25/22 at 11:52 PM: Nurses Note . alert, resting in bed, has one steri strip over left eye . -2/27/22 at 11:07 PM: Nurses Note . resting in bed, no distress, has one steri strip over left eye, has purple bruising to both eye corners. no further injuries noted from fall . - 3/2/22 at 11:37 AM: Social Service Note . Resident's new glasses arrived at facility today . Note: Resident #11's MDS detailed the Resident did not wear corrective lenses. - 8/30/22 at 1:25 PM: eInteract Change in Condition Evaluation . Falls .Skin Evaluation . Contusion . Discoloration . left side of forehead . Is the Resident cognitively able to rate their pain: Yes . (pain rating not documented) . Pain location: Headache . Abrupt onset of progression of severe headache . change in mental status, or focal neurological abnormalities . location of pain . left side of forehead . left arm/shoulder . Resident was found on floor in room after attempting to self-transfer from wheelchair. C/o (complain of) right arm/shoulder pain - 8/30/22 at 1:30 PM: Nurses Note . Writer called to resident's room by CENA staff after resident was discovered on floor in room. Resident admits was attempting to self-transfer from wheelchair at time of incident. Resident was assessed and transferred from floor to bed via Hoyer lift by staff. Large raised purple contusion apparent to left side of forehead on initial assessment by writer. She also c/o (complain of) left arm pain, MD notified. No further abrasions/skin tears, etc. noted at this time. Pain reported and PRN (as needed) Tylenol administered. Resident is currently resting comfortable in bed at this time . - 8/30/22 at 2:10 PM: Nurses Note . Nurse reported resident fall in room and new orders for left arm Xray r/t pain following fall. Writer went into assess resident, who was laying in bed awake at that time. Resident's left elbow was bent with hand laying near left shoulder, when writer asked resident if could straighten arm said no. No bruising or swelling was observed on hand, wrist, forearm, or elbow. Writer lifted resident's short sleeve shirt to assess shoulder and it appeared shoulder was dislocated. Contacted physician to verify if we should obtain Xray at facility or send to ER for possible dislocation, physician ordered to send to ER for evaluation . - 8/31/22 at 5:01 AM: Incident Note . Resident has bruise to left forehead and right shoulder is painful post relocation. PRN (as needed) Tylenol given for a PAINAD (Pain Assessment IN Advanced Dementia- scale used to assess and determine pain level in individuals with dementia and/or other cognitive impairments who are unable to verbally communicate pain levels) of 4 for right (sic) shoulder . - 8/31/22: Physician's Note Late Entry . Fall with resultant shoulder dislocation unfortunately on the left side with a left femoral (sic) fracture for which was sent to the emergency room . They have put on a sling and then requested her to follow with orthopedic surgeon which we will arrange . does have discomfort and pain which is actually being controlled with the help of pain medication . Exam . 1. The patient actually is in the sling at the present time . 2. Left femur fracture . - 9/1/22 at 12:22 AM: Nurses Note .resting in bed, Tylenol given for c/o pain in shoulder, with noted effect. sling in place. bruise above left eye . - 9/2/22 at 12:14 AM: Nurses Note . resident resting in bed, assisted with meals, left arm in sling, bruise remains above left eye, denies c/o pain at this time . - 9/2/22: Physician's Note Late Entry . Follow-up on a recent event . fall with left humeral fracture. We are waiting for orthopedic evaluation for this patient . pain control seems to be adequate . was transferred to the hospital . had a shoulder displacement which was put in place in the ER but unfortunately sustained a humeral fracture also, for which is in a sling . - 9/6/22 at 3:46 PM: Nurses Note . Resident returned from f/u (follow up) appt with (orthopedic physician) this shift. Suggestions include PT/OT, NWB to left hand, finger, wrist with ROM to be completed in therapy. Sling to worn AAT (at all times) when not in therapy . - 10/10/22 at 12:11 PM: Nurses Note . Per ortho follow-up, resident may discontinue non-weight bearing status to LUE and discontinue sling use to left arm at this time. Weight bearing as tolerated to left arm . - 11/29/22 at 12:16 PM: Physician's Note Late Entry . Follow-up on fracture of the greater tuberosity of the humerus . continues to require some pain control . Impression/Plan .In addition for the non-displaced fracture of the greater tuberosity of the humerus, will continue to require pain control . Review of Resident #11's hospital medical record documentation revealed the Resident's dislocated shoulder was reduced (put back in place) in the ER. Diagnostic imaging reports dated, 8/30/22 at 5:21 PM detailed, XR (X-Ray) Shoulder Complete 2+ Views Left . Reason . fall, pain, trauma . Findings . 1. Anterior inferior dislocation (uncommon dislocation) of the humeral head in relation to the glenoid. 2. Acute displaced fracture (broken bone pieces do not line up) involving the greater tuberosity of the humeral head. Questionable irregularity of the underlying glenoid (hallow socket in the shoulder blade where the head of the humerus sits) which may also represent fracture . On 1/20/23 at 2:13 PM, Resident #11 was observed in their room, in bed. When queried if they had gotten out of bed today, Resident #11 replied, No. With further inquiry, Resident #11 revealed they were having pain. Review of Resident #11's Pain Level Summary documentation in the EMR revealed the last documented pain level was on 10/29/22. Review of Resident #11's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2023 revealed no documentation of pain level assessment. Review of the facility-provided Incident and Accident (I and A) reports for Resident #11 revealed the Resident had two similar unwitnessed falls while sitting in their wheelchair in their room. The I and A details included: - 2/23/22 at 10:35 AM: Fall . Resident's room . Nursing Description: Called to resident room by activities staff, observed resident laying on floor on right side with CNA holding head up. CAN stated they entered the room, resident was laying face down next to bed with wheelchair flipped on top of them and foot pedals wedged between resident chest and floor. Prior to fall, resident was sitting in chair next to bed . Call light not in use. Footwear was in place. Laceration and bruising noted to residents left eyebrow. Large bruise and goose egg noted to resident's mid forehead. Abrasion and bruising noted to resident's right chest where foot pedal was wedged. Small abrasion noted to left pointer finger . Resident Description: Resident stated . was trying to get self to stand up but legs didn't work . Immediate Action Taken . Assessed resident for injuries . Neuros WNL although resident's pupils were not reactive. Laceration and bruising noted to residents left eyebrow. Large bruise and goose egg noted to resident's mid forehead. Abrasion and bruising noted to resident's right chest where foot pedal was wedged. Small abrasion noted to left pointer finger. Resident was cleaned up and assisted off the floor . Injuries Report Post Incident: No Injuries Observed Post Incident . Predisposing Environmental Factors: (Blank) . Predisposing Physiological Factors . Weakness/Fainted . Predisposing Situational Factors . Call light not used . Other Info: Resident attempted to self-transfer, although has not been ambulatory since admission . The I and A did not detail if Resident #11's call light was located within reach at the time of their call, if the wheelchair brakes were locked, the position of the footrests prior to the fall, and/or interventions implemented to prevent future falls. - 8/30/22 at 1:25 PM: Fall . Resident's Room . Nursing Description . Writer called to resident's room by CNA staff at 1325 (1:25 PM) to report resident found on floor . Upon entering room . observed resident lying on left side on the floor in front of wheelchair that was tipped in the forward position. Resident was lying on left shoulder/arm and left side of face was on the floor. Call light was not in use . Resident Description: Resident states . was getting up & 'trying to find out what was going on.' At the time of the incident, fire alarm test was performed and was attempting to get up and see what was happening, following door being closed during test . Immediate Actions Taken: Resident assessed . Large purplish contusion observed to left side of forehead and potential shoulder separation/dislocation noted following residents c/o pain to left arm/shoulder area . No further abrasions or known issues noted . Orders received transfer to hospital for further eval . Resident taken to hospital: N (No) . Injuries Report Post Incident: No Injuries Observed Post Incident . Predisposing Environmental Factors: (Blank) . Predisposing Physiological Factors . Drowsy . Impaired Memory . Incontinent . Predisposing Situational Factors . Ambulating without Assist . Notes . IDT met to review resident, front anti-tippers added to wheelchair and care plan. Tilted seat ordered for wheelchair . Review of Resident #11's care plans revealed a care plan entitled, Risk for falls r/t epilepsy, hx falls, muscle weakness, medications . (Created and Initiated: 8/19/19; Revised 2/18/20). The care plan included the interventions: - Call light accessible (Initiated: 8/19/19) - Make sure my brakes are locked before every transfer (Initiated: 8/19/19) - Encourage and assist resident to lay down after meals (Initiated: 9/13/20) - Dycem to between pants and total lift sling and coccyx cushion and total lift sling in wheelchair to prevent sliding (Created: 3/25/21; Initiated: 3/24/21) - Therapy eval r/t fall (Created: 2/24/22; Initiated: 2/23/22) - Front anti-tippers to high back wheelchair (Initiated: 8/30/22) - Drop (tilted) seat to wheelchair (Initiated: 9/12/22) Review of Resolved interventions in the care plan revealed there were no additional interventions implemented and discontinued following Resident #11's falls. An interview was conducted with the DON on 1/25/23 at 11:10 AM. When queried regarding Resident #11's falls, the DON confirmed the Resident had two unwitnessed falls in their room while sitting in their wheelchair. The DON was queried regarding the injuries Resident #11 sustained from their fall on 8/30/22 and revealed the Resident had dislocated and fractured their left shoulder. When asked about inconsistent documentation of which shoulder was painful/injured and Physician documentation indicated the Resident had fractured their femur (leg), the DON replied, They did not fracture their femur and indicated the documentation was in error and would need to contact the Physician to have them fix it. When queried what happened when the Resident fell , the DON stated it was right after a fire drill and revealed the Resident had attempted to get up out of their wheelchair by themselves. When queried if the Resident was made aware a fire drill was occurring and the reason for their door being closed, the DON replied, No and indicated staff and Residents are not alerted of upcoming drills for preparedness. When asked if staff tell residents the reason their doors have to be closed and if they provide any additional instructions, the DON did not provide a response. The DON was then queried what interventions were implemented following the fall and replied, Front anti-tippers and tilted seat (to wheelchair). When queried regarding Resident #11's fall on 2/23/22, the DON indicated the Resident had fell out of their wheelchair in the room but did not sustain any major injuries. When queried regarding the Resident's head laceration and if any diagnostic testing had been completed, the DON indicated the Resident was treated in the facility. When asked about the inconsistent documentation pertaining to the injuries including a note detailing the resident did not have any bruising or injuries, the DON was unable to provide an explanation. When queried regarding the Physician/Health Care Provider not assessing the Resident following the fall until 3/18/22 and not addressing the fall in their documentation, the DON did not provide an explanation. The DON was then asked what interventions were implemented following the fall in February to prevent future falls and injury. The DON reviewed Resident #11's EMR and stated, Referred to therapy. The DON was then queried regarding the location of the call light at the time of the fall, if the wheelchair brakes were locked, location of other items in the room, when the Resident had last been observed, and/or the position of the wheelchair foot pedals for both falls. The DON indicated the Resident would have been visualized by staff when they shut the room door for the fire drill on 8/30/22 but were unable to provide a specific time. No additional explanation was provided. When asked if they had any additional information regarding the falls and if an investigation had been completed, the DON indicated they did not think there was any additional information but would look. An interview was completed with Certified Occupational Therapy Assistant (COTA) Therapy Director E on 1/25/23 at 1:32 PM. When queried regarding Resident #11's fall on 2/23/22 and referral to therapy services, Director E indicated they were not employed on a full-time basis until recently and were not familiar with the Resident's falls and/or treatments. Resident #11's therapy documentation including the evaluation following their fall on 2/23/22 was requested at this time. Review of Resident #11's provided therapy documentation included the following: - Evaluation and discharge documentation from 6/16/20 to 7/3/20 treatment certification period - 3/21/22: Occupational Therapy (OT) . Evaluation and Plan of Treatment . Prior Equipment . w/c with high back, elevating leg rests and side support . Safety Awareness = Impaired . RUE (Right Upper Extremity) ROM WFL (Within Functional Limits) . LUE ROM = WFL . Has Patient fallen in past year? Yes; How many times? = Exact number unknown; Was patient injured from fall? Yes; Injury description: minor injuries . Reason for Therapy . Pt. (patient) also has difficulty maintaining seated position in w/c and often has slid out of w/c secondary to becomes lethargic and unable to maintain upright position . - 8/31/22: Occupational Therapy (OT) . Evaluation and Plan of Treatment . Reason for Referral / Pt was referred to OT services secondary to falling out of w/c when fire drill went off. Pt was sent to hospital and was found to have dislocated L shoulder and L non-displaced fx of L greater tuberosity and large contusion on forehead . Pt does not have any orders for weight bearing and ROM precautions. will default to no ROM at shoulder and NWB (Non-weight Bearing) of LUE . RUE ROM = WFL; LUE ROM = DNT (Do Not Treat) (fx); Clinical Reason(s) = Severe fracture (Greater tuberosity and shoulder dislocation. However pt returned from hospital with no ROM or weight bearing orders. Building attempting to get pt in to see ortho and get further instructions) . Does Patient worry about falling? = Yes . Pt has poor safety and judgement and can be impulsive at times . Clinical Impressions/Reason for Skilled Services: Pt recently had a fall and it resulted in L shoulder dislocation and fx of greater tuberosity. Pt is Dependent with bed mobility and having difficultly feeding and oral hygiene secondary to unable to use LUE . - 9/26/22 (signed date): Skilled Interventions Provided: PROM (Passive Range of Motion)/ AAROM (Assisted Active Range of Motion) with LUE. Pt has difficulty following ROM and weight bearing restrictions . able to complete AAROM with therapist present to provide appropriate positioning of LUE . Pt was participating with therapy services however was sent out to hospital . - 10/3/22: Occupational Therapy (OT) . Evaluation and Plan of Treatment . Pt is resident of this facility and was recently on OT/ST services prior to going to hospital. OT was looking into Fx UE . was found to have aspiration pneumonia . has returned to this facility from hospital . Reason for Therapy . still under precautions for L shoulder restrictions. NWB of LUE and no Shoulder ROM. Pt was in sling however unable to locate sling upon return . - 10/27/22 (date signed): OT Discharge Summary . Assessment and Summary of Skilled Services . Direct, hands-on care with patient this reporting period focused on the following skilled interventions . now WBAT (Weight Bearing as Tolerated) and can use arm as appropriate . No documentation for therapy evaluation/treatment following the Resident's fall on 2/23/22 was provided. On 1/25/23 at 4:35 PM, an interview was completed with Clinical Care Coordinator (CCC)/Staff Development Registered Nurse (RN) D. When queried if Resident #11 was evaluated and treated by Therapy in February 2022, RN D revealed they would need to check. A follow-up interview was completed with RN D on 1/25/23 at 4:42 PM. RN D revealed they had spoke to Therapy and reviewed the EMR. RN D stated, Therapy did not do an evaluation in February because (Resident #11) was already on Speech Therapy. No further information was provided. On 1/25/23 at 4:47 PM, a second interview was completed with the DON. When queried why Resident #11 was not seen by Therapy services following the fall on 2/23/22, the DON revealed they were not aware the Resident had not been seen. The DON proceeded to review the EMR and indicated the Resident was seen by therapy as part of their quarterly (MDS) screen but did not receive services/treatment. The DON was then asked if any other interventions, including nursing interventions, had been implemented to prevent future falls and revealed no interventions had been implemented. When asked if the nursing staff had implemented any immediate interventions to ensure Resident #11's safety, the DON replied, No immediate interventions. With further inquiry, the DON revealed they would be working with staff regarding the importance of implementing immediate interventions following falls. When queried regarding investigation to identify potential causes of the falls in order to implement appropriate and meaningful interventions, the DON indicated falls are discussed in the IDT meetings. No additional investigation documentation was provided. When queried why the interventions implemented following the fall on 8/30/22 including front anti-tippers and a tilted seat to Resident #11's wheelchair were not implemented following the fall on 2/23/22, the DON was unable to provide an explanation. Review of facility provided policy/procedure entitled, Falls Reduction Program (Revised 9/25/16) revealed, Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall- related injury . Procedure . 2. Implement and indicate individualized interventions on Care Plan/Kardex . 3. If fall occurs Charge Nurse to complete the following: Physical assessment of resident and observation of environment . Immediate interventions as identified by physical assessment and environmental observation . 3.1. Initiate safety interventions and update care plan as applicable . 3.2. Charge nurse to monitor for delayed consequences of incident utilizing the following . Physical assessment and documentation . Neurological Assessment per directions, as applicable . 3.3. IDT to review each incident to complete root cause analysis . 3.4.2. Complete/review Fall Assessment . Discuss and determine root cause . Summarize IDT analysis in the incident report .

Based on observation, interview and record review, the facility was placed in Immediate Jeopardy due to their failure to institute and operationalize appropriate Infection Control practices in accordance with the Centers for Disease Control and Prevention's (CDC) recommended measures of Cohorting and Isolation of residents diagnosed with [REDACTED]. This included implementation of appropriate interventions, such as Transmission Based Precautions, proper use and storage of Personal Protective Equipment (PPE) and diagnostic testing to prevent the spread of respiratory infections. The failure to maintain infection control practices resulted in the likelihood for a serious adverse outcome including infectious illness and death if appropriate Infection Prevention and Control Standards of Practice were not enacted. Immediate Jeopardy: Tour of the facility: On [DATE] at 1:55 PM, an initial tour of the facility was conducted with the Director of Nursing (DON) who was the Infection Preventionist. room [ROOM NUMBER] had a transmission based precaution sign on the door that had instruction for contact, droplet and airborne precautions but did not indicate which precaution the Resident was on. The DON was queried regarding the Resident's precautions and reported the Resident was on precautions due to [MEDICAL CONDITION] treatments. When queried how people entering the room would know what to wear, the DON indicated a sign that instructed to Stop, See Nurse Before Entering. An observation was made of no gowns in the caddy that had gloves, procedure masks and bags and no gowns were near the Resident's door. When queried if staff were to wear a gown in the room the DON reported the gowns were stored in the shower room. The shower room was down the hall and was entered by placing a code on the lock to open the door. An open bin was observed sitting on the floor of the shower room with gowns inside the bin. The DON explained that the gowns are reusable and when they get them back, they are hard to fold and look messy if put in the caddy. The gowns were not easily accessible for the Resident residing in room [ROOM NUMBER]. Plastic sheeting was near room [ROOM NUMBER] that went from floor to ceiling and had a cutout area for a door that was fastened with paper clips. An observation was made of a lack of a seal around the door. The DON reported that area was the Covid-19 unit and the door was there but staff entered and exited the unit from the outside door. When queried why Resident in room [ROOM NUMBER] was next to the Covid-19 Unit, the DON reported there were no positive Covid-19 Residents in the Covid-19 Unit. The area where staff enter the building was observed with strings on the wall that had paper bags clipped to the string where staff PPE was stored. Some of the bags had masks in them and were touching other bags. Behind some of the bags, goggles and face shields were stored. The goggles and face shields were touching multiple bags and it was not determined upon observation which goggles or face shield belonged to which staff member whose names were written on the bags. A tour of the observation/monitoring unit was conducted. Staff had a KN95 mask on with a procedure mask over top. Staff removed gowns before coming out of the Resident's room but kept the KN95 and procedure mask on. Each Resident door had a transmission based precaution sign on the door that indicated contact, droplet and airborne precautions. No gowns were noted near the resident room doors. The CNA working the unit was asked about the gowns and reported the gowns were kept in the beauty shop. The gowns were observed in the beauty shop near the entrance to the unit. There were gowns piled on a chair just inside the open door and were observed to be short sleeved gowns and partially covered by a sheet. The CNA reported going to the beauty shop room to get a gown prior to entering another Resident's room on the monitoring unit. When queried regarding the use of the KN95 or N95 mask, the DON reported the staff wear the KN95 and that the N95 were for use on the Covid-19 unit. When queried if N95 mask were available, the DON reported they had N95 masks available but was unsure how many. At 5:35 PM, an observation was made with the DON of the Covid-19 Unit. The plastic sheeting was opened by removal of the paper clips and another plastic sheeting was up that had another door held together with paper clips. When queried regarding the space for the Covid-19 unit the DON reported the Covid Unit consisted of room [ROOM NUMBER] beds A and B, room [ROOM NUMBER] beds A and B and room [ROOM NUMBER] beds A and B and room [ROOM NUMBER] was a break room and supply room. The DON reported that when they had more Residents with Covid-19, that the wall was expanded outwards to accommodate more rooms. An observation of the staff break room/supply room revealed a Resident room that appeared to be converted to a break room/supply room with its own bathroom. There was a bed with linen on it stored in the room with an over bed table next to it and items stacked on top of and around the bed. There was blue tape on the floor in the hallway near the door to go outside. When queried regarding the blue tape on the floor, the DON reported that the area within the blue tape was the dirty area where staff could take off gowns and put them in the linen baskets and the clean area where staff came into the unit from the door was on the other side of the blue tape. The clean area was a couple feet from the door to the blue tape on the floor and the dirty area was a couple feet wide with the Resident rooms starting just past the blue tape on the floor. Staff had an area on the wall of the unit that had a string with clips that had paper bags with N95 masks and goggles that were clipped and stored on the string. When queried regarding the PPE, the DON reported the staff re-used N95 masks and goggles and kept them there where they also screened to come into the Covid-19 Unit. During a tour of the facility on [DATE] at 10:35 AM with the Director of Nursing (DON) and Corporate Infection Control Nurse U, a Resident #8 was observed walking briskly towards the Nurses desk/common area from the West Hall. He was not wearing a mask. The DON asked the resident where his mask was, and he stopped and looked at her; she handed him a mask and helped him put it on. He turned and continued walking through the building. The dining room was observed to have several residents sitting at tables with Social Distancing. The DON said the facility had opened the dining room for eating and activities the week prior but was unsure of the exact date. Also, during the tour, prior to entering the closed South Hall Covid Observation/Monitoring unit for New Admissions, hanging string with clipped on paper bags was observed in the hallway prior to entering the unit. The DON said this was where staff stored their N95 masks for reuse. Some of the bags were clipped on top of each other and either were not labeled with the staff members name or several different staff had bags stored on top of each other. The DON said this was not proper storage of the masks and said she would correct it. The 300 South Hall Observation/Monitoring unit was observed to have 10 residents on the unit with signs on the doors that they were in Transmission Based Precautions. There was no PPE on the doors or outside of the rooms. The DON said the PPE was in the Beauty Shop towards one end of the hallway. The DON was asked if staff had to walk down the hallway to the Beauty Shop each time, they needed new PPE and said, Yes. Upon entering the Beauty Shop, Short-Sleeved hospital gowns were observed for use as PPE. The DON confirmed the gowns were worn by staff as part of the Transmission Based Precautions for residents with exposure to someone with positive Covid-19 or with signs and symptoms of Covid-19 on the South and West Hallways. The DON was asked how the Observation/Monitoring unit was staffed and said the Nurse assigned to the 100 West hall was also assigned to the 300 hall Observation/Monitoring unit, one aide was assigned to the monitoring unit depending on the census and an aide from the 100 East hall came over to help. Centers for Disease Control and Prevention (CDC), update [DATE] Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings; The Healthcare Infection Control Practices Advisory Committee (HICPAC): Using Personal Protective Equipment (PPE): . Isolation gowns are used as specified by Standard and Transmission-Based Precautions, to protect the HCW's (Healthcare Worker's) arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material . The wearing of isolation gowns and other protective apparel is mandated by the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard . Full coverage of the arms and body front, from neck to the mid-thigh or below will ensure that clothing and exposed upper body areas are protected . Cohorting is the practice of grouping together patients who are colonized or infected with the same organism to confine their care to one area and prevent contact with other patients . During the facility tour on [DATE] at 11:00 AM, the East Hall was observed to have a Visqueen (plastic barrier), taped along the wall, floor and ceiling, towards the end of the hallway. There was a flap in the middle held loosely with clips. There was PPE and an Isolation sign outside the door of room [ROOM NUMBER], which was located next to the barrier. The DON was asked why the resident (#7) was in precautions and she said he [MEDICAL CONDITION] and was receiving [MEDICAL CONDITION]. The DON was asked if the resident had precautions in place to protect the resident from exposure to illnesses that other people might bring into the room and she said, Yes. When asked when the Covid unit last had Covid-19 positive residents in it, the DON said it had been about 2 weeks. The DON was asked how long the resident had resided in room [ROOM NUMBER] next to the Covid unit and she said it had been a while. Upon entry into the Covid unit, the DON said there were four rooms in the unit: 201, 202, 203 and 204. She said 201 was a break room for staff working on the Covid unit and the other rooms were designated for Covid-19 positive residents. The DON said the rooms were currently empty, as there were no Covid positive residents in the building. room [ROOM NUMBER] was used by staff for a break room while they were working on the Covid-19 unit. The break room had a table and several chairs, medication cart, treatment supplies and a variety of other items stored in the room, including a bed with linens on it and items stored on top of the linens. The DON was asked if the bed and stored items were in the room while it was used for staff working on the Covid unit and said, Yes. A large exit door (approximately 4 feet wide) was located at the end of the hallway inside the Covid unit. There was a blue line of tape on the floor approximately 4 feet from the exit door and about ,[DATE] feet from the first resident's Covid room. Between the blue tape and the exit door were bins with PPE. A string with clips was hanging on the wall of the Covid unit. Corporate IC Nurse U said the string was where the staff hung paper bags to store used N95 masks (in the hallway of the Covid-19 unit for Covid positive residents). The paper bags were used to allow moisture to evaporate from the masks through the bags to the outside air, but they would also allow infectious organisms to gather on the outside of the bags. The Corporate Nurse said the staff entered and exited the Covid unit through the exit door to the outside and upon entering, would stop inside the Covid unit and put on their N95 mask, face shield or goggles, gown and gloves and then proceed over the blue line to care for the residents. The DON and Corporate IC nurse were asked why the staff were donning PPE in the hallway, so close to the exit door, because when the outside door opened, and a resident room door would open there would be a strong pull of air circulating in the hallway, which could increase circulation of the Covid-19 virus. The Corporate IC Nurse said, This is how we do it. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, [DATE] and updated Feb. 23, 2021, . CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients . Respirator, Put on an N95 respirator (or equivalent or higher-level respirator) . eye protection . gowns . gloves . before entry into the patient room or care area (ex. Covid unit) . Centers for Disease Control and Prevention (CDC): The National Institute for Occupational Safety and Health (NIOSH), [DATE], Pandemic Planning: Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings . Safe N95 reuse is affected by a number of variables that impact respirator function and contamination over time . If reuse of N95 respirators is permitted, respiratory protection program administrators should ensure adherence to administrative and engineering controls to limit potential N95 respirator surface contamination . Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other and the person using the respirator is clearly identified. Storage containers should be disposed of or cleaned regularly . Avoid touching the inside of the respirator . Use a pair of clean (non-sterile) gloves when donning a used N95 respirator and performing a user seal check. Discard gloves after the N95 respirator is donned and any adjustments are made . Association for Professionals in Infection Control and Epidemiology (APIC): APIC Position Paper: Extending the Use and/or Reusing Respiratory Protection in Healthcare Settings During Disasters, [DATE], . Respiratory protection is only one strategy for preventing infection spread during an infectious disease disaster. The Centers for Disease Control and Prevention (CDC) has outlined a hierarchy of control measures . These guidelines serve as the foundation for recommendations on extending the use and reuse of respirator outlined in this document. Other critical interventions for preventing infection spread during an infectious disease disaster include source control (eliminating potential exposures) . promptly isolating potentially contagious individuals . the exterior of respiratory protection used in caring for patients with respiratory pathogens . can become contaminated and serve as a reservoir for infectious agents. Special precautions must be taken when extending the use or reusing disposable respiratory protection to prevent healthcare personnel exposure . The respirator should be stored in a clean, dry location that prevents it from being contaminated and maintains its physical and functional integrity . Store the respirator in a breathable container such as a paper bag . the container/bag is a single use item because the inside can become contaminated due to storing a used respirator; therefore, the container/bag should be discarded after the respirator is redonned . After touring the Covid unit and exiting back out the flap of the plastic barrier to the unit, the DON was asked if the Covid unit had always been confined to rooms ,[DATE] and she said, No, we had to expand it a couple times to include the whole 200 hall (,[DATE]). The DON was asked what the dates of the expansions were and said she would have to look it up. The DON was asked how many Covid positive staff and residents the facility had, and she said they had an outbreak of Covid that started in [DATE] and continued through [DATE]. The facilities last Covid test for residents and staff was [DATE] and the results had not yet been received. The DON was asked how long it took to receive the Covid-19 test results and she said it varied from 48 hours to longer and all tests were sent out to a laboratory for processing as the facility was not performing Rapid on-site tests. A review of the facility Respiratory Line Listings for [DATE] - February 2021 revealed the following: 1. From [DATE]th, 2020 to [DATE], 30 residents from an approximate facility census of 41 (73%) contracted the Covid-19 virus. 2. Seven of the 30 (23%) Covid-19 positive residents died . 3. Twenty-two facility staff tested positive for Covid-19 from [DATE] - [DATE]; One additional staff member tested positive from the [DATE] testing for a total of 23 - Covid-19 positive staff. A review of the Facility Testing Manifests for Residents and Staff from [DATE] - [DATE] indicated there were 4 residents and 8 staff with Indeterminate or Invalid Covid-19 testing results on the Testing Results Manifests, received by the facility from the laboratory that processed the specimens. Retests for the Residents and staff ranged from ,[DATE] days later. All of the residents and several of the staff tested positive with Retests for Covid-19. The facility was unable to indicate why they did not address the inconclusive results sooner, immediately retest the staff and residents and implement preventive measures to reduce the spread of infection to other residents and staff. Centers for Disease Control and Prevention (CDC): Testing Guidelines for Nursing Homes: [DATE] and updated [DATE]: Interim [DIAGNOSES REDACTED]-CoV-2 Testing Guidelines for Nursing Home Residents and Healthcare Personnel, Nursing home residents are at high risk for infection, serious illness, and death from COVID-19. Testing for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19, in respiratory specimens detects current infections (referred to here as [MEDICAL CONDITION] testing) among residents in nursing homes. [MEDICAL CONDITION] testing of residents in nursing homes, with authorized nucleic acid amplification tests or [MEDICATION NAME] detection assays, is an important addition to other infection prevention and control (IPC) recommendations aimed at preventing [DIAGNOSES REDACTED]-CoV-2 from entering nursing homes, detecting cases quickly, and stopping transmission . Testing conducted at nursing homes should be implemented in addition to recommended IPC (Infection Prevention and Control) measures . Testing practices should aim for rapid turnaround times (ideally less than 24 hours) of [DIAGNOSES REDACTED]-CoV-2 (Covid-19) testing results to facilitate effective interventions . A review of a document received from the facility Director of Nursing on [DATE] titled, Covid wall placement, detailed the dates the plastic sheeting wall for the Covid unit was expanded on the 200 hall to accommodate the increasing number of Covid-19 positive residents: [DATE] - first use of unit- (rooms) ,[DATE]. [DATE]- wall expanded - ,[DATE]. [DATE]- wall expanded - ,[DATE]. [DATE]- wall expanded - ,[DATE]. [DATE]- wall moved back - ,[DATE]. A record review for Residents #'s 13 and 33 indicated each resident's room was located within the enclosed Covid-19 positive unit during the time period prior to the Resident testing positive for Covid-19. Further review of the resident's medical records revealed each resident was documented as being in a room within the Covid unit during the timeframe that the Covid unit was housing Covid positive residents, but Residents #'s 13 and 33 were Covid negative. Upon clarification, facility clinical staff said the location and date of the resident's rooms was documented on the Census and Room Change documents in each resident's medical record. Resident #13's room (203-B) was on the Covid unit when it first opened on [DATE] and remained in the room for the duration of his stay. Resident #13 was negative for Covid-19 until [DATE] and died on [DATE]. Resident #33's room was located within the Covid unit from [DATE]-[DATE] (204-B). The resident was Covid-negative and moved out of the unit until [DATE] when he tested positive for Covid-19 and returned to the Covid unit (207-A). On [DATE], the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) issued the following recommendations: . to help mitigate the spread of the 2019 Novel Coronavirus (Covid-19) . designate separate facilities or units within a facility to separate Covid-19 negative residents from Covid-19 positive residents and individuals with unknown Covid-19 status . Long-term care facilities should separate patients and residents who have Covid-19 from patients and residents who do not, or have an unknown status . Covid-19 positive units and facilities must be capable of maintaining strict infection control practices and testing protocols, as required by regulation . The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified on [DATE] of the Immediate Jeopardy that began on [DATE]. The Immediate Jeopardy Abatement (Removal) Plan was approved on [DATE] with a Removal Date of [DATE]. Findings Include: An interview with the DON/Infection Control Nurse, on [DATE] at 9:05 AM, related to the Infection Control Program revealed she had assumed the role of the Infection Prevention and Control Nurse shortly after the prior IC Nurse and Director of Nursing left in mid-[DATE]. Upon review of Covid infections in the facility, the DON said the first positive staff member was in the middle of [DATE] and several more staff tested positive a few weeks later. More staff continued to test positive after that and on the [DATE] resident testing manifest, (results received [DATE]) several residents tested positive. The facility had a continuous outbreak of Covid-19 from the end of [DATE] through [DATE]. The DON said the facility began twice a week testing for residents around [DATE]th, 2020. The [DATE]- [DATE] Respiratory Surveillance was reviewed with the DON. During the interview, the DON was asked what interventions were enacted to prevent the spread of infection and said, We opened the Covid unit, wore PPE including, N95 masks and screened the staff and residents. The DON was asked if any additional interventions were attempted after the staff and residents continued to test positive for almost 2 months and she said, No, we continued with the interventions we had in place. The DON was questioned about the opening of the dining area and Activities and she said the facility had opened the dining room for eating and Activities on February 4th, 2021 and in [DATE] also; she was asked for the dates that the dining room was open in December and was not sure. In [DATE] there was less than a 14-day break between positive staff and residents. On the [DATE] Respiratory Line List, it indicated 2 Covid-19 positive staff members on [DATE] and 2 positive Residents on [DATE]. In between that timeframe from [DATE]rd- [DATE]th, three staff members had signs and symptoms of Covid-19 including, sore throat, cough, runny nose, achiness, headache and tiredness, but did not test positive for Covid-19. There was never a span of time during the month when staff or residents either were not symptomatic or testing positive for Covid-19. The DON was asked how a determination was made that it was safe for the residents and staff to gather together when there was an outbreak of Covid-19 in the building and she said she wasn't sure who made the decision to open the dining room. On further review of the [DATE] and January/February Respiratory Line List with the DON it was identified that in [DATE], thirteen residents and 6 staff tested positive for Covid-19; eight staff developed signs and symptoms of Covid-19 but did not test positive. In [DATE] residents and 4 staff tested positive for Covid-19 in the first week of the month ([DATE]st-7th), with a total for the month of 17 residents and 11 staff that tested positive for Covid-19. During the interview, the DON and Corporate Infection Control (IC) Nurse U were asked what masks the staff were wearing during the outbreak, as staff were observed wearing KN95 masks that were not snug over the bridge of their noses (there were air gaps) and the DON said Our PPE did change at that time. They wore KN95 masks for the entire building and N95 masks on the Covid unit when it opened. They were asked if there were enough N95 masks for all clinical staff, as Covid-19 had been identified in residents on each hallway (100 West, 200 East and 300 South) and the DON stated, I'm not sure who supplies them; If it's our supplier or somewhere else. The Corporate IC Nurse U replied, I'm not sure who they are using. It's our policy to wear KN95's on all units except for the Covid unit. They wear N95's. The DON was asked what the process was when a resident had signs and symptoms of Covid-19 and said, We would leave them in the 'Transition' room (their own room with Transmission Based Precautions). The DON was asked what gowns the staff were wearing for precautions on the 100 West and 300 South Halls (7 of 13 Covid positive residents were from the 100 West and 300 South halls in [DATE]) and all of the Covid positive staff and staff with signs and symptoms of Covid were working on the South or West halls, she said the staff were wearing the washable hospital gowns. The DON was asked if those were the short-sleeved gowns and she stated, Yes, they are resident hospital gowns. They wear the long-sleeved yellow disposable gowns on the Covid unit. Reviewed with the DON that short-sleeved gowns were not appropriate for PPE use with Transmission Based Precautions. They do not cover the arms to the wrist, so that when protective gloves are applied, they can be pulled over the cuff on the gown to completely protect the staff member from exposure to infectious organisms, which they might then carry to other staff and residents. The staff members were not protected from exposure to Covid-19. During the interview on February 10th, 2021 with the Director of Nursing and Corporate IC Nurse U, they were asked when the Covid unit was placed into use and the DON said the Covid unit was created on [DATE] when the first Covid-19 positive residents were identified. The first 2 Covid positive residents (tested [DATE] with results on [DATE]) were from the South hall (rooms [ROOM NUMBERS]) and were moved to the Covid unit (200 East Hall) on [DATE]. The DON said on that date the rooms consisted of ,[DATE] with room [ROOM NUMBER] to be used as a break room. She said the plastic barrier went up on that date. The [DATE] Respiratory Line Listing indicated that after the Covid unit was enacted 6 residents from the 200 East Hall tested positive for Covid-19: room [ROOM NUMBER]A tested positive [DATE]; room [ROOM NUMBER] tested positive [DATE]; room [ROOM NUMBER] on [DATE], room [ROOM NUMBER]B tested positive on [DATE]; room [ROOM NUMBER] B tested positive on [DATE] and room [ROOM NUMBER]A tested positive on [DATE]. room [ROOM NUMBER] B was identified as contained within the Covid unit beginning [DATE], but the remainder of the 6 rooms were located directly outside of the plastic barrier wall of the Covid unit. The residents tested positive shortly after (within 12 days), the Covid unit was placed in use near their rooms. The DON stated, Eventually, we had moved the wall back so that the entire hallway was the Covid unit- Rooms ,[DATE]. In [DATE] additional residents in rooms in the East Hall- 211 A ([DATE]) and B ([DATE]) and 212 A ([DATE]) and B ([DATE]) tested positive for Covid-19. Almost all of the residents located outside of the Covid unit tested positive for Covid-19. Also, in [DATE], all staff that tested positive for Covid-19 were working on the South (300 Hall), East (200 Hall) and Covid units (,[DATE]- first use of unit ,[DATE]; ,[DATE]- wall expanded ,[DATE]; ,[DATE]- wall expanded ,[DATE]; ,[DATE]- wall expanded ,[DATE]; ,[DATE]- wall moved back ,[DATE]). On [DATE] at 12:50 PM an interview with Confidential Person DD provided, I worked in the Covid unit and people were not wearing their PPE correctly. We had to put on our N95 mask in the hallway of the Covid unit. We stored them in paper bags in the hallway of the unit. I didn't want to get Covid. No one does. The Confidential Person was asked what type of Isolation gown was worn to care for the residents and stated, We had the yellow paper gowns. You can throw them away, but in the rest of the building they wore hospital gowns. The Confidential Person was asked if the hospital gowns were long-sleeved gowns and said, No, they were short-sleeved. On [DATE] at 11:45 AM, during an interview with Corporate Clinical Nurse O, she was asked for information on how to identify which room the resident was in during their stay at the facility and said, the information would be found in the Census tab in the resident's electronic medical record with the room number and date they first occupied the room. She said the information could also be located on the Room Change form found in the resident's electronic medical record. It would include the room number and date the resident moved from one room to another. During the interview, the Corporate Clinical Nurse O was also asked about the use of gowns for Transmission Based Precautions and stated, They use long-sleeved gowns always on the Covid positive unit, but hospital gowns with precautions on the other units. Asked if the hospital gowns were short-sleeved and she said, Yes. Discussed the safety risks for staff and residents with not using appropriate preventive measures when caring for residents in Transmission Based Precautions to decrease the potential exposure to Covid-19. The Corporate Nurse O said she did not know why the facility was not using the yellow long-sleeved gowns on each unit. On [DATE] at 2:30 PM Interview with Nurse FF about working on the Covid unit revealed, I don't leave my mask there in a bag. I don't keep it there in the facility. When I walk in the building, I have a mask on. I want to be protected. The Nurse was asked what type of Isolation gowns were worn on the unit and stated, They were wearing short sleeved gowns on the non-Covid unit and yellow and blue long sleeve gowns on the Covid unit. The Nurse was asked about the rooms located in the Covid unit and stated, As we got more Covid patients, we moved our plastic down to more rooms. Nurse FF was questioned about what room Resident #13 was in and stated, He was in room [ROOM NUMBER]B in the Covid unit. He passed right there. An interview with Housekeeping Supervisor KK on [DATE] at 9:06 AM, about washable Isolation gowns used by the facility revealed, We have since changed that. We don't use the short-sleeved hospital gowns since last week. On [DATE] at 9:25 AM, during an interview with Central Supply Clerk X said the facility did not have a shortage of the long-sleeved Isolation gowns and stated, We have never had any trouble getting gowns. There was a few times they said they were on back order but then they would send them. On [DATE] at 9:30 AM, an interview with the Certified Dietary Manager EE about the dining room opening for meals and Activities provided, We opened to limited capacity about 2 weeks ago. It was opened in December (2020) for a short time: 10 tables-marked, 6 feet apart with a capacity of 10 residents. An interview with the Activities Director on [DATE] at 9:40 AM related to restarting group activities with the residents provided, I believe it was on the 4th ([DATE]). We can allow 10 residents. The Activities Director was asked if the facility had started group activities in [DATE] and stated, We were testing twice a week. We would open and shut down. Someone would test (TRUNCATED)

This Citation Pertains to Intake #MI 547 Based on interview and record review, the facility failed to assess, monitor and notify the physician and family with abnormal vital signs and a change of condition for 1 (#1) of 3 residents reviewed for abnormal vital signs and a change of condition, resulting in Resident #1 developing a worsening condition leading to [MEDICAL CONDITION] requiring resuscitation efforts and death. Findings Include: A review of the Face Sheet and Minimum Data Set (MDS) assessment revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment, dated [DATE], indicated the resident needed extensive 2-person assistance with bed mobility, transfers, dressing, hygiene and toileting and an extensive 1-person assistance with bathing. The resident died on [DATE]. A review of the Nurses Progress Notes dated [DATE] revealed the following: 8:05 AM- Resident yelling out, rolled on left side with face in the enabler bar and arms hanging off bed. Educated on safety and need to move off side of bed. resident refused to move off side of bed. face remains resting on enabler bar. arms remain off bed. [MEDICAL CONDITION] bil arms noted. Resident resisting repositioning. Continues to yell out very loudly. [MEDICATION NAME] given 30 minutes early to help with pain control. 11:16 AM- Resident is quiet. Laying on left side with face against enabler bar and arms hanging of bed. Continues to resist personal care and repositioning by yelling out and refusing to be repositioned. Educated on safety while in bed, verbalized understanding, remained on left side. 1:12 PM- Resident incontinent of urine, brief and bed wet with urine. Resident extremely anxious, confused, throwing body around bed, swinging arms and legs, yelling out loudly. Noncompliant with any personal hygiene. Holding on to enabler bar and refusing to let go, roll over to back. Spoke calmly with resident to participate with brief change. Brief was changed and bed linens changed. Resident continued to be noncompliant through this task. Yelling just let me rest, After brief changed resident again turned to left side and pushed face up against enabler bar and refused to be repositioned. This nurse gave resident pain medication and anxiety medication which resident swallowed without difficulty. Resting on left side at this time. The next Progress Note was at 9:41 PM and revealed, Resident woke up for dinner around 1745 (5:45 PM) and was screaming out for help me and calling out for CNA (Certified Nursing Assistant) by name for approximately 2 hours. All staff attempted to reassure and care for resident and was unable to calm resident. Resident rested in wheelchair until was woken up to get into bed and was screaming out for help for 20 minutes until finally able to get assistance to place in bed. PRN (as needed) [MEDICATION NAME] given as ordered. There was no documentation that the physician was notified of the resident's anxiousness, yelling for help or discomfort on [DATE]. A review of the Vital Signs for Resident #1, documented in the Weights and Vitals Report indicated the following at approximately 3:13 AM on [DATE]: Blood Pressure- ,[DATE] (normal range ,[DATE]-,[DATE]), Pulse -107 beats per minute (normal range ,[DATE]), Respirations - 30 per minute (normal range ,[DATE]). At 3:13 AM/Temperature 102.1 and 3:57 AM a Temperature of 102.5 `F was documented (normal range 97.8 to 99.1). Each of the Vital Signs was much higher than normal for Resident #1. There was no documentation that the resident was further assessed to aid in determining a cause or that the physician or family were notified of the abnormal Vital Signs. A review of the Medication Administration Record [REDACTED]. Medication that could decrease the resident's pain and lower the fever. The Vital Signs were retaken approximately 4 hours later on the day shift and while improved, were not all in the normal range; The Blood Pressure was elevated at ,[DATE]. A review of the Progress notes for [DATE] revealed a Vitals Note, Data Warning, computer generated alert was listed for the Pulse/107, Respirations/30 and Temperature/102.5. At 6:57 AM to 7:09 AM Nurse H documented, No s/s (signs and symptoms) of distress, for each abnormal vital. A Progress Note dated [DATE] at 9:37 AM and written by Nurse H provided, Called to resident's room by nurse related to non-responsiveness. 9:45 AM Code Blue (cardiopulmonary resuscitation/cpr) was called. Husband and 911 called . The note further said that Emergency Medical Services (EMS) arrived and assisted with CPR and at 10:32 AM CPR was stopped, as the resident had died . The resident's physician was then notified. A review of Resident #1's Care Plans revealed the following: Cardiac Issues, Care Plan dated [DATE]/8 with Interventions, [DATE] Hypertension (high blood pressure): assess/document/report to MD PRN (as needed) any s/s of severe headache, fatigue, confusion, vision problems, chest palpitations . Assess/Document/Report to MD PRN for s/s bleeding: rapid increased heart rate, low blood pressure, paleness or pallor, confusion, weakness, gum bleeding . Actual alteration in oxygen exchange r/t Respiratory disease: [MEDICAL CONDITION], Care Plan Date Initiated: [DATE], Observe for s/sx of respiratory distress and report to MD PRN: Abnormal respiratory rate, pulse ox, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage . During an interview with Nurse H (a day shift nurse) on [DATE] at 1:25 PM, the nurse was queried about her response to Resident #1's abnormal Vital Signs on the prior shift (midnights/Nurse H worked day shift) and her documentation of No s/s of distress, and responded, I usually clear the Weights and Vitals, If anything abnormal comes up, I try to hurry and do that in the morning. I walked up and down the halls and looked in each resident's room. I saw her lying in bed. We obviously didn't get anything in report about a problem. If they did, we would have rechecked that. Every shift is supposed to clear them (The Vital Sign Alerts). I don't know what was happening on the other shift (midnights). Nurse H indicated the Nurse Aides usually obtained the Vital Signs, documented them in the computer and left a written list for the Nurse to see. During an interview the Director of Nursing (DON) on [DATE] at 3:08 PM stated, I did not find a note about them contacting the physician about the abnormal Vital Signs. On [DATE] at 3:32 PM, during an interview Physician J was asked about Resident #1's abnormal Vital Signs, Code Blue and death and stated, Usually they'll let me know in the morning. No one called me. I don't remember her having fevers. They said she had a huge mucous plug and couldn't clear it during CPR. She had been complaining about anxiety. An interview with Nurse I on [DATE] at 3:51 PM provided, I recall (Resident #1) running a temp (fever) and she said she didn't feel good and was having pain. I gave her a [MEDICATION NAME] and it brought her pain down. When asked if there was assessment documentation related to the abnormal Vital Signs and pain, Nurse I stated, It should have been in a note. We would monitor and make a Nurses Note. Nurse I was asked about the Vital Signs Data Warnings and replied, You should monitor and retake them if they are out of the norm. You would call the doctor. An interview with Confidential Person K on [DATE] at 8:57 AM revealed, (Resident #1) said she wasn't feeling good the day before ([DATE]). She didn't act like herself. No one talked to me about it. A review of the facility policy titled Change of Condition, dated [DATE] provided, The attending physician .will be notified with changes in a resident's condition or health status .Acute symptoms: Temperature of 101 degrees or higher .change in vital signs .unmanageable behavior .notify supervisor .Document time of call, physician or nurse practitioner or other person spoken to, reason for call and result or orders received.

THIS CITATION PERTAINS TO INTAKES MI 715 AND MI 739. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT AVOIDABLE ACCIDENTS FOR 3 (#101, #102 AND # 105) OF 5 SAMPLED RESIDENTS, ALL REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 5, RESULTING IN INJURY. FINDINGS INCLUDE: RESIDENT #101: ACCORDING TO THE FACE SHEET DATED [DATE], RESIDENT #101 HAD LIVED IN THE FACILITY SINCE [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #101 WAS A [AGE] year OLD FEMALE WITH SEVERELY IMPAIRED COGNITION AND WAS COMPLETELY DEPENDENT ON STAFF TO ASSIST WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING TRANSFERS. SHE HAD SEVERAL [DIAGNOSES REDACTED]. THE CARE PLAN DATED [DATE] INDICATED THAT RESIDENT #101 WAS TOTALLY DEPENDENT ON STAFF FOR ALL HER DAILY CARE NEEDS AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING THE ASSISTANCE OF TWO STAFF MEMBERS FOR ALL TRANSFERS, AND THE USE OF A MECHANICAL LIFT FOR ALL TRANSFERS. ACCORDING TO THE UNUSUAL OCCURRENCE REPORT DATED [DATE], RESIDENT #101 fell FROM A LIFT WHEN BEING TRANSFERRED FROM THE WHEELCHAIR TO THE BED. ACCORDING TO THE NURSE'S NOTES DATED [DATE] AT 1:10 P.M., RESIDENT #101 WAS BEING TRANSFERRED FROM THE WHEELCHAIR TO THE BED BY THE USE OF A MECHANICAL LIFT WITH THE ASSISTANCE OF 2 STAFF MEMBERS WHEN THE TOP LEFT SLING HOOK OF THE LIFT BECAME DISENGAGED FROM THE LIFT HOOK AND RESIDENT #101 fell TO THE FLOOR. RESIDENT #101 WAS ASSESSED AND FOUND TO HAVE SUFFERED A 4 CM LACERATION FROM STRIKING THE LEFT SIDE OF HER HEAD ON THE FLOOR. ACCORDING TO THE NURSE'S NOTES, RESIDENT #101 WAS SENT TO THE LOCAL AREA HOSPITAL FOR ADDITIONAL CARE AND TREATMENT AT 1:30 P.M. ACCORDING TO THE NURSE'S NOTES, RESIDENT #101 WAS UNRESPONSIVE AT THE HOSPITAL AT 3:30 P.M. ACCORDING TO THE HOSPITAL PHYSICIAN NOTE DATED [DATE], RESIDENT #101 WAS SUFFERING FROM CEREBRAL BLEEDING (BLEEDING IN THE BRAIN), CEREBRAL EDEMA (SWELLING OF THE BRAIN) AND A HEAD HEMATOMA (A SOLID SWELLING OF CLOTTED BLOOD WITHIN THE TISSUES). ACCORDING TO THE RADIOLOGY REPORT DATED [DATE], RESIDENT #101 SHOWED EVIDENCE OF EDEMA AND HEMORRHAGE IN THE LEFT FRONTAL LOBE OF HER BRAIN, WHICH MAY HAVE BEEN REFLECTIVE OF A TRAUMATIC CEREBRAL CONTUSION (A FORM OF TRAUMATIC BRAIN INJURY). ACCORDING TO FACILITY RECORDS, RESIDENT #101 WAS REadmitted to the facility on [DATE] AND WAS admitted TO HOSPICE CARE (A TYPE OF CARE AND A PHILOSOPHY OF CARE WHICH FOCUSES ON THE RELIEF OF SYMPTOMS OF A TERMINALLY ILL PATIENT). RESIDENT #101 died on [DATE]. ACCORDING TO THE RESIDENT #101'S DEATH CERTIFICATE DATED [DATE], THE CAUSE OF RESIDENT #101'S DEATH WAS DEHYDRATION. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO THE DEATH INCLUDED WAS RESIDENT #101'S HEAD INJURY. DURING AN INTERVIEW ON [DATE] AT 12:49 P.M., THE CERTIFIED NURSE ASSISTANT (CNA #1) SAID THAT SHE WAS ONE OF THE NURSE ASSISTANTS WHO TRANSFER RESIDENT #101 ON [DATE]. CNA #1 REVIEWED HER SIGNED STATEMENT FROM THE INVESTIGATIVE REPORT AND SAID IT WAS ACCURATE. CNA #1 SAID "AFTER LUNCH WE USUALLY LAY (RESIDENT #101) DOWN FOR A REST." CNA #1 SAID THAT ON [DATE] SHE AND THE OTHER STAFF MEMBER (CNA #2) HAD A STUDENT WITH THEM. CNA #1 SAID SHE PUT RESIDENT #101'S WHEELCHAIR IN FRONT OF HER (#1) BETWEEN THE BED AND THE SINK. CNA #1 SAID SHE WAS ON RESIDENT #101'S RIGHT SIDE AND CNA #2 WAS ON THE LEFT SIDE. CNA #1 SAID THAT AS THE STAFF MEMBERS WERE LIFTING HER (RESIDENT #101) UP WITH THE SLING AND WHILE GUIDING HER BY THE LOOP ON THE BACK OF THE SLING, THE LEFT SHOULDER SLING HOOK CAME LOOSE AND RESIDENT #101 fell TO THE FLOOR, HITTING THE LEFT SIDE OF HER FOREHEAD ON THE FLOOR. CNA #1 CLARIFIED THAT THE LEFT SHOULDER SLING HOOK DID NOT BREAK; IT CAME LOOSE FROM THE LIFT HOOK. CNA #1 WAS UNABLE TO EXPLAIN HOW THE SLING'S WEBBING LOOP COULD HAVE COME OUT OF THE FOUR INCH DEEP CURVED HOOK IF THE SLING LOOP WAS CORRECTLY PLACED IN THE LIFT. CNA #1 SAID, "...WE THOUGHT IT (RESIDENT #101 ' S SLING) WAS ALL HOOKED UP ...GUESS IT WASN'T." IN AN INTERVIEW ON [DATE] AT 1:06 P.M., CERTIFIED NURSE ASSISTANT (CNA #2)SAID SHE WAS ASSISTING CNA #1 WITH RESIDENT #101'S TRANSFER ON [DATE] WHEN RESIDENT #101 fell . CNA #2 SAID SHE WAS STANDING BEHIND THE LIFT, REACHING AROUND IT TO PUT RESIDENT #101 IN THE LIFT. CNA #2 SAID SHE COULD NOT REACH THE STRAPS WELL FROM WHERE SHE WAS STANDING, BUT SHE DID PUT RESIDENT #101'S LEFT SIDE SLING STRAPS ON THE LIFT. CNA #2 SAID, "...I REMEMBER IT WAS VERY HARD TO REACH FROM WHERE I WAS (STANDING)..." CNA #2 SAID ONCE THEY PUT THE STRAPS ON THE LIFT HOOKS, SHE AND CNA #1 BEGAN TO MOVE RESIDENT #101. CNA #2 SAID THAT WHEN SHE CLOSED THE LEGS, THE TOP LEFT STRAP CAME LOOSE AND RESIDENT #101 "...fell HEAD FIRST ONTO THE FLOOR..." CNA #2 SAID THE SLING STRAP DID NOT BREAK, IT CAME OUT. CNA #2 SAID THE LIFT HOOK MUST HAVE JUST CAUGHT ON THE EDGE OF THE STRAP WHEN BEING CONNECTED TO THE LIFT INSTEAD OF ACTUALLY BEING IN THE BOTTOM OF THE HOOK. CNA #2 SAID ...WE DIDN'T NOTICE THAT IT WASN'T IN THE RIGHT PLACE...MAYBE I LOOKED AT THE WRONG LOOPS, OR IT SHIFTED BEFORE WE RAISED HER UP...I THINK THE STRAP MUST HAVE BEEN TEETERING ON THE TOP OF THE HOOK...MAYBE I DIDN'T LOOK AT THEM (RESIDENT #101 ' S LIFT STRAPS) AT ALL..." ON [DATE] AT 1:22 P.M., CNA #1 SAID THAT BOTH SHE AND CNA #2 TOOK THE TIME TO EXPLAIN TO THE STUDENT THAT YOU HAVE TO CHECK THE HOOKS FOR PROPER PLACEMENT IN THE LIFT, BUT THEN SAID "...I DON'T RECALL CHECKING..." CNA #1 SAID MAYBE THE OTHER CNA DID. "...IT WAS BOTH OF OUR JOBS TO CHECK, BUT I DIDN'T CHECK TO SEE THAT IT WAS (CORRECTLY PLACED)..." CNA #1 SAID THE STRAP PROBABLY WAS NOT ACTUALLY IN THE HOOK, "...AND THEN IT fell OFF WHEN WE MOVED HER..." CNA #1 SAID, "...I DON'T KNOW IF THE OTHER CNA EVEN CHECKED HER SIDE...IT WAS JUST ONE BIG DISASTER...WE'RE SUPPOSED TO DOUBLE AND TRIPLE CHECK THE STRAPS...WE WERE IN SUCH A RUSH, JUST LIKE ALWAYS... BUT IF WE HAD JUST CHECKED THE STRAPS IT WOULDN'T HAVE HAPPENED." ACCORDING TO THE ADMINISTRATIVE INVESTIGATION SUMMARY DATED [DATE], "IT APPEARS THE HOOP WAS NOT FULLY ON (THE) HOOK OF HOYER (LIFT)." DURING AN INTERVIEW ON [DATE] AT 2:24 P.M., THE MAINTENANCE DIRECTOR (MM #1) SAID HE BELIEVED IT WOULD HAVE BEEN BENEFICIAL TO HAVE SAFETY CLIPS ON THE HOOKS SO THAT STAFF WOULD HAVE TO FORCE THE STRAPS TO FULLY ENGAGE THE LOOPS INTO THE HOOKS. MM #1 SAID THAT SAFETY CLIPS WOULD HAVE ALSO PREVENTED ANY DISPLACEMENT OF THE SLING LOOPS FROM OCCURRING. MM #1 SAID HE "...TOLD THEM (FACILITY STAFF) ABOUT THE LACK OF CLIPS (SAFETY) YEARS AGO..." MM #1 SAID THERE WAS NO REAL PROBLEM WITH THE LACK OF THESE CLIPS, BUT IT WOULD HAVE BEEN AN EXTRA SAFETY FEATURE. MM #1 SAID THE LIFT WAS DESIGNED WITH EXTRA DEEP FINGERS TO PREVENT THE STRAPS FROM COMING OFF WHEN THE SLING LOOPS WERE INSERTED CORRECTLY. MM #1 SAID THE LIFT HAS FOUR INCH DEEP CURVED HOOKS, AND "...THE ONLY WAY THIS COULD HAVE HAPPENED WOULD HAVE BEEN MISUSE OF THE LIFT, OR RUNNING INTO SOMETHING THAT WOULD HAVE CAUSED (RESIDENT #101) TO BOUNCE UP AT LEAST FOUR INCHES..." MM #1 SAID THAT TO THE BEST OF HIS KNOWLEDGE THERE WERE "...NO SPEED BUMPS IN THE FACILITY..." IN AN INTERVIEW ON 11:38 A.M., THE DIRECTOR OF NURSING (DON #1) SAID THAT DURING THE COURSE OF THE FACILITY'S INVESTIGATION, THE EVENTS SURROUNDING RESIDENT #101'S FALL WERE REENACTED. DON #1 SAID THAT RESIDENT #101 WAS NOT AGGRESSIVE AND WAS NOT VIOLENT. DON #1 SAID RESIDENT #101 WAS OLDER AND FEEBLE AND WAS NOT ABLE TO MOVE HER OWN BODY WEIGHT. DON #1 SAID RESIDENT #101 "...DID NOT DO A LOT OF MOVEMENT..." AND COULD NOT HAVE SHIFTED HERSELF. "...THE ONLY WEIGHT SHIFT WOULD HAVE COME FROM THE MOVEMENT OF THE (LIFT)...THERE'S NO WAY IT (RESIDENT #101'S SLING) WOULD HAVE COME OFF (THE LIFT HOOK) IF IT WAS IN THE BOTTOM OF THE HOOK..." DON #1 SAID THAT ALL FACILITY STAFF ARE TAUGHT TO MAKE SURE THE SLING LOOPS ARE PROPERLY PLACED IN THE LIFT BUT SAID THAT IN ORDER FOR RESIDENT #101 TO HAVE FALLEN, STAFF "...MUST HAVE FAILED TO CONNECT THE SLING PROPERLY TO THE LIFT ARM..." ( ) RESIDENT #102: ACCORDING TO THE FACE SHEET DATED [DATE], RESIDENT #102 LIVED IN THE FACILITY SINCE [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #102 WAS AN [AGE] year OLD ALERT FEMALE WHO WAS UNDERSTOOD VERBALLY AND REQUIRED STAFF ASSISTANCE AND SUPERVISION WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING TOILETING AND TRANSFERS. RESIDENT #102 HAD SEVERAL [DIAGNOSES REDACTED]. THE CARE PLAN DATED [DATE], INDICATED THAT RESIDENT #102 WAS AT RISK FOR FALLS, HAD VISION PROBLEMS, NEEDED A STAFF PERSON TO WALK WITH HER AND NEEDED STAFF TO ASSIST HER WITH TOILETING. ACCORDING TO THE NURSE'S NOTE DATED [DATE] AT 4:00 A.M., RESIDENT #102 COMPLAINED THAT SHE HAD AN "...ONGOING..." PROBLEM WITH DIFFICULTY MOVING HER BOWELS. ACCORDING TO THE NURSE'S NOTES, ALTHOUGH RESIDENT #102'S BOWEL RECORDS SHOWED NO RECENT PROBLEM WITH CONSTIPATION, RESIDENT #102 WAS GIVEN PRUNE JUICE BECAUSE SHE WAS "...WORRIED ABOUT BEING CONSTIPATED..." ACCORDING TO THE NURSE'S NOTES, THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH AMBULATION AND TOILETING WHEN AT 10:00 P.M., RESIDENT #102 WAS FOUND ON THE FLOOR IN THE BATHROOM. RESIDENT #102 SUSTAINED NO DOCUMENTED INJURIES AT THE TIME. THE UNUSUAL OCCURRENCE REPORT DATED [DATE] IDENTIFIED THAT RESIDENT #102 TRANSFERRED WITHOUT ASSISTANCE, TOILETED WITHOUT ASSISTANCE AND AMBULATED WITHOUT ASSISTANCE, WAS NOT WEARING SHOES AND DID NOT USE HER WALKER, ALL ACTIONS THAT WERE NOT CONSISTENT WITH RESIDENT'S PLAN OF CARE AND CLEARLY CONTRIBUTED TO HER FALL. ( ) RESIDENT #105: ACCORDING TO THE FACE SHEET DATED [DATE], RESIDENT #105 LIVED IN THE FACILITY SINCE [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #105 WAS A [AGE] year OLD ALERT FEMALE, WHO WAS UNDERSTOOD VERBALLY, WAS UNSTEADY WHEN WALKING TRANSFERRING AND TOILETING, AND REQUIRED STAFF ASSISTANCE AND SUPERVISION WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING TOILETING AND TRANSFERS. SHE HAD SEVERAL [DIAGNOSES REDACTED]. RESIDENT #105 WAS ASSESSED AT HIGH RISK FOR FALLS AND ACCORDING TO THE CARE PLAN DATED [DATE], SEVERAL INTERVENTIONS WERE IMPLEMENTED INCLUDING ASSISTANCE WITH TRANSFERS, AN ANTI/ROLLBACK DEVICE ON HER WHEELCHAIR, ASSISTANCE WITH ALL AMBULATION, REMINDING NOT TO AMBULATE WITHOUT ASSISTANCE, REMINDING TO CALL STAFF FOR ASSISTANCE, MAKE SURE CALL LIGHT IN REACH, FREQUENT VISUAL CHECKS TO MAKE SURE THE RESIDENT WAS NOT MOVING ABOUT THE ROOM INDEPENDENTLY, AND A NOTIFICATION TO THE STAFF THAT RESIDENT #105 DISABLED HER ALARMS FREQUENTLY. A REVIEW OF RESIDENT #105'S CLINICAL RECORD REVEALED MANY FALLS FOR RESIDENT #105, BUT ONLY 10 OF THESE INDIVIDUAL FALLS WERE REVIEWED. THE FALLS REVIEWED BY THE SURVEYOR OCCURRED BETWEEN [DATE] AND [DATE]. ACCORDING TO THE NURSE'S NOTES DATED [DATE], THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH AMBULATION AND TRANSFERS WHEN AT 7:45 A.M., RESIDENT #105 WAS FOUND ON THE FLOOR IN FRONT OF HER WHEELCHAIR BETWEEN TWO BEDS IN HER ROOM. RESIDENT #105 WAS ASSESSED AND IT WAS FOUND SHE SUFFERED A 6 IN X 1 IN REDDENED AREA ON HER "LEFT SIDE" AND A REDDENED AREA THE SIZE OF A QUARTER ON HER RIGHT ELBOW. RESIDENT #105'S CARE PLAN WAS UPDATED ON [DATE] TO INCLUDE GRABBER BARS X 2 (ON BOTH SIDES), A GRIPPER PAD/CUSHION TO HER WHEELCHAIR, WHEELCHAIR AND BED ALARMS, ANTI/TIPPERS ON HER WHEELCHAIR, ASSISTANCE WITH TOILETING, AND A SCHEDULED TOILETING PROGRAM. ACCORDING TO THE NURSE'S NOTES DATED [DATE], THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH TOILETING, AMBULATION AND TRANSFERS WHEN AT AN UNDOCUMENTED TIME, RESIDENT #105 "...fell BACK AGAINST CUPBOARD ATTEMPTING TO SELF TRANSFER..." IN THE ACTIVITY ROOM BATHROOM. RESIDENT #105 WAS ASSESSED AND IT WAS FOUND SHE SUFFERED A TENDER AREA LOCALIZED TO A PINK MARK FOUND ON HER BACK. ACCORDING TO THE NURSE'S NOTES, STAFF "...REMINDED (RESIDENT #105) SHE NEEDS TO ASK FOR ASSISTANCE..." ACCORDING TO THE UNUSUAL OCCURRENCE REPORT, DATED [DATE], RESIDENT #105 WAS IMPULSIVE AND DID NOT WAIT FOR ASSISTANCE. ALTHOUGH THE ACTIVITY ROOM BATHROOM WAS LOCKED AS A RESULT OF THE OCCURRENCE, NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #105. ACCORDING TO THE NURSE'S NOTES DATED [DATE], THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH TOILETING, AMBULATION AND TRANSFERS WHEN AT 7:20 A.M., RESIDENT #105 WAS AGAIN FOUND ON THE FLOOR IN THE BATHROOM. RESIDENT #105 SAID "...I TURNED (OFF) MY ALARM OFF AND WALKED TO THE BATHROOM..." RESIDENT #105 WAS ASSESSED AND FOUND TO HAVE SUFFERED AN ABRASION OF UNDOCUMENTED SIZE ON HER RIGHT FOREARM AND FOOT. ON [DATE] RESIDENT #105'S CARE PLAN WAS UPDATED WITH THE NOTATION, "...REVIEWED, NO CHANGES AT THIS TIME..." ACCORDING TO THE UNUSUAL OCCURRENCE REPORT DATED [DATE], FACILITY STAFF WERE TO "...CONTINUE WITH CURRENT INTERVENTIONS IN PLACE," HOWEVER, "...INCREASED SUPERVISION..." WAS DOCUMENTED. NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #105. ACCORDING TO THE NURSE'S NOTES DATED [DATE], THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH TOILETING, AMBULATION AND TRANSFERS WHEN AT 9:10 A.M., RESIDENT #105 fell on TO THE TOILET IN THE BATHROOM WHILE TOILETING AND TRANSFERRING UNASSISTED. RESIDENT #105 WAS ASSESSED AND IT WAS FOUND SHE SUFFERED TWO REDDENED AREAS ON HER LOWER BACK MEASURING 3 CM BY 5 CM EACH FROM STRIKING A PLUMBING FIXTURE. ACCORDING TO THE UNUSUAL OCCURRENCE REPORT SUMMARY DATED [DATE], "...THIS IS NOT UNUSUAL FOR THIS RESIDENT...WILL CONTINUE WITH OTHER INTERVENTIONS AS OUTLINED ..." THE UNUSUAL OCCURRENCE REPORT DID ALERT STAFF TO UTILIZE 2 PERSON ASSISTANCE WITH TOILETING WHEN NEEDED. ACCORDING TO THE UNUSUAL OCCURRENCE REPORT, "...INCREASED SUPERVISION ..." WAS IMPLEMENTED, HOWEVER NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY INCREASED SUPERVISION HAD BEEN IMPLEMENTED. ACCORDING TO THE NURSE'S NOTES DATED [DATE] THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH AMBULATION AND TRANSFERS WHEN AT 8:30 A.M., RESIDENT #105 FOUND ON THE FLOOR IN THE DAYROOM. RESIDENT #105 SAID SHE AGAIN TURNED HER ALARM OFF. RESIDENT #105 WAS assessed with [REDACTED]. ACCORDING TO THE UNUSUAL OCCURRENCE REPORT DATED [DATE], NO CHANGES WERE MADE IN RESIDENT #105 ' S CARE PLAN. ON [DATE] RESIDENT #105 ' S CARE PLAN WAS UPDATED WITH THE NOTATION, "...NO CHANGE IN CARE PLAN AT THIS TIME..." NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #105. ACCORDING TO THE NURSE'S NOTES DATED [DATE], THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH AMBULATION, TRANSFERS AND TOILETING WHEN AT 1:40 A.M., RESIDENT #105 WAS AGAIN FOUND ON THE FLOOR IN THE BEDROOM, THIS TIME LYING ON HER LEFT SIDE. RESIDENT #105 SAID SHE AGAIN TURNED ALARM OFF. AGAIN RESIDENT #105 SUFFERED NO OBVIOUS INJURIES FROM THE INCIDENT. STAFF NOTIFIED THE PHYSICIAN, BUT THERE WERE NO "...NEW ORDERS..." ACCORDING TO THE NURSE'S NOTES DATED [DATE], THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH AMBULATION, TRANSFERS AND TOILETING WHEN AT 6:15 P.M., RESIDENT #105 WAS FOUND ON THE FLOOR IN THE BATHROOM, WITH HER PERSONAL ALARM TURNED OFF. ACCORDING TO THE UNUSUAL OCCURRENCE REPORT DATED [DATE], RESIDENT #105 WAS ASSESSED AND IT WAS FOUND SHE SUFFERED FROM A BRUISED ELBOW. THERE WAS AGAIN NO CHANGE IN CARE PLAN HOWEVER THE NEED FOR "...INCREASED SUPERVISION..." WAS DOCUMENTED. NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #105. ACCORDING TO THE NURSE'S NOTES DATED [DATE] AT 3:30 P.M., RESIDENT #105 WAS OBSERVED TURNING OFF HER ALARMS. NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE THAT THE FACILITY INITIATED ANY NEW INTERVENTIONS TO DEAL WITH RESIDENT #105'S ABILITY TO TURN THE ALARM OFF AT WILL AND TO PREVENT ACCIDENTS FOR RESIDENT #105. THEN, ACCORDING TO THE NURSE'S NOTES ON THE SAME DAY ([DATE]) AT 7:15 P.M., THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH AMBULATION, TRANSFERS AND TOILETING; AND RESIDENT #105 fell on THE FLOOR IN THE BATHROOM. RESIDENT #105 SAID SHE AGAIN TURNED HER ALARM OFF. ACCORDING TO THE UNUSUAL OCCURRENCE REPORT DATED [DATE] RESIDENT #105 WAS ASSESSED AND SHE WAS FOUND TO HAVE SUFFERED A BRUISED ELBOW. ACCORDING TO THE UNUSUAL OCCURRENCE REPORT RESIDENT #105'S SAFETY INTERVENTIONS WERE REVIEWED, AND IT WAS FOUND SHE REQUIRED AN ALARMING SEAT BELT FOR SAFETY. ACCORDING TO THE NURSE'S NOTES DATED [DATE] AT 11:30 A.M., RESIDENT #105 COMPLAINED OF PAIN TO LEFT RIBS AND AN X/RAY WAS ORDERED. ACCORDING TO THE RADIOLOGY REPORT DATED [DATE] RESIDENT #105 SUFFERED FROM FRACTURES OF THE 5TH 6TH AND 7TH RIBS. ACCORDING TO THE NURSE'S NOTES DATED [DATE] THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH AMBULATION, TRANSFERS AND TOILETING AND AT 6:30 A.M., RESIDENT #105 fell TO THE FLOOR IN THE BEDROOM. ACCORDING TO THE NURSE'S NOTES, RESIDENT #105 SAID SHE WAS TRYING TO GET TO THE BATHROOM. ACCORDING TO THE UNUSUAL OCCURRENCE REPORT DATED [DATE] RESIDENT #105 WAS ASSESSED AND NO OBVIOUS INJURY WAS FOUND. NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #105. ACCORDING TO THE NURSE'S NOTES DATED [DATE], RESIDENT #105 WAS ASSESSED AND A "...RED SPOT ON THE (RESIDENT #105'S) LEFT LOWER BACK ..." WAS FOUND. ACCORDING TO THE UNUSUAL OCCURRENCE REPORT DATED [DATE] RESIDENT #105 WAS BEING ASSISTED WITH TOILETING BY ONE STAFF AND STOOD. ACCORDING TO THE UNUSUAL OCCURRENCE REPORT, "...WITH BOTH HANDS, I (CERTIFIED NURSING ASSISTANT #3) PULLED HER UNDERPANTS UP AND SHE STARTED TO SLID (SLIDE)." RESIDENT #105 fell "...BASICALLY ON TOP OF (THE) CLOTHES BASKET ..." AS CNA #3 "...YELLED FOR HELP..." DURING AN INTERVIEW ON [DATE] AT 1:34 P.M., THE CERTIFIED NURSE ASSISTANT (CNA #3) SAID SHE (#3) WAS THE ONLY PERSON ASSISTING RESIDENT #105 IN THE BATHROOM. CNA #3 SAID RESIDENT #105 WAS UNSTEADY ON HER FEET, BUT WAS STANDING WITH NO ASSISTANCE WHEN SHE WENT TO PULL UP RESIDENT #105'S UNDERPANTS. CNA #3 SAID RESIDENT #105 WAS AT THE TIME BEING ASSISTED WITH DRESSING BUT SHE WAS NOT HELPING RESIDENT #105 MAINTAIN HER (#105) BALANCE. CNA #3 SAID SHE HAD NO KNOWLEDGE OF THE [DATE] INTERVENTION TO UTILIZE 2 PERSON ASSISTANCE WHEN TOILETING RESIDENT #105, BECAUSE RESIDENT #105 "...WAS NOT MY PATIENT..." IN AN INTERVIEW ON [DATE] AT 11:50 A.M., THE CLINICAL CONSULTANT (CC #1) SAID "ALARMS DO NOT PREVENT FALLS, HOWEVER, WE DO EXPECT THAT IF ALARM USE IS DISCONNECTED BY THE RESIDENTS, OTHER THINGS MUST BE PUT INTO PLACE LIKE SUPERVISION TO ENSURE RESIDENT SAFETY." DURING AN INTERVIEW ON [DATE] AT 1:46 P.M., THE DIRECTOR OF NURSING (DON #1) WAS GIVEN THE OPPORTUNITY TO REVIEW RESIDENT #105'S CLINICAL RECORD INCLUDING THE UNUSUAL OCCURRENCE REPORTS. DON #1 SAID THAT OF THE 10 FALLS REVIEWED THE FACILITY ONLY IMPLEMENTED NEW INTERVENTIONS ON 2 OCCASIONS, AFTER THE FALLS THAT OCCURRED ON [DATE] AND ON [DATE]. DON #1 SAID THAT ON 3 OCCASIONS INCREASED SUPERVISION WAS IMPLEMENTED. DON #1 EXPLAINED THAT "...INCREASED SUPERVISION MEANS ...I DON'T KNOW WHAT THAT MEANS...I NEED TO BE MORE CLEAR..." DON #1 WAS UNABLE TO EXPLAIN WHAT OTHER THINGS WERE PUT INTO PLACE, FOR EXAMPLE, SUPERVISION, TO ENSURE RESIDENT #105'S SAFETY WHEN SHE REPEATEDLY DISABLED THE ALARMS. DON #1 SAID AFTER MOST OF THE FALLS, NO CHANGES WERE MADE IN RESIDENT #105'S SUPERVISION OR ASSISTIVE DEVICES THAT MAY HAVE PREVENTED AVOIDABLE ACCIDENTS FOR RESIDENT #105. DON #1 SAID THE FACILITY CONTINUED TO USE A PLAN THAT "...WAS NOT WORKING..." AND WHERE THE REQUIRED SUPERVISION WAS NOT PROVIDED. ( )