Every finding on record at Forest Health & Rehab Center

Based on interview, record review, document review, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of resident property for 1 (Resident #98) of 4 sampled residents reviewed for abuse. Specifically, Licensed Practical Nurse (LPN) #18 misappropriated Resident #98's oxycodone pain medication without the resident's permission on 04/11/2025.Findings included: A facility policy titled, Virginia Resident Abuse Policy revised 07/11/2024, indicated, POLICY: The facility will not tolerate the abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy specified, Misappropriation - the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. A Resident Face Sheet revealed the facility admitted Resident #98 on 03/18/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of pain, osteoarthritis, and low back pain. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/2025, revealed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had frequently, almost constant pain received a scheduled pain medication regimen and as needed pain medication. Resident #98's Care Plan included a problem statement initiated 04/03/2025, that indicated the resident had a potential for pain related to a sacral wound, gastroenteritis and colitis, pain, cramp and spasm, low back pain, and osteoarthritis of the hip. Interventions directed staff to administer medications for pain prior to therapy sessions, dressing changes as needed, or per specific orders (initiated 04/09/2025). Resident #98's Order History for the timeframe 03/01/2025 to 09/09/2025, revealed an order dated 03/28/2025, for oxycodone 5 milligrams, one tablet every four hours as needed. The Facility Reported Incident Investigation indicated on 04/14/2025, the Social Services Director (SSD) notified the Director of Nursing (DON) that Resident #98's family member (FM) that the resident had not been given their as needed pain medication as requested on 04/11/2025. Per the Facility Reported Incident Investigation, upon review of the narcotic control count log sheet for oxycodone, three tablets were removed on 04/11/2025 by Licensed Practical Nurse (LPN) #18 and the resident declined receiving the prescribed narcotic pain medication. The Facility Reported Incident Investigation revealed Conclusion Upon a complete and thorough investigation, the facility is able to substantiate medication diversion. This is evidenced by resident statements and narcotic count review on 4/14/25. [Name] Pharmacy, the local police dept [department] and the provider have been notified of this. There has not been any identified negative outcome as a result of the diversion of medications. All residents including [Resident #98] remain safe in the facility at this time. Telephone calls were made to LPN #18 on 09/11/2025 at 2:35 PM and 09/12/2025 at 9:00 AM. There was no answer and the voicemail had not been set up. The DON was interviewed on 09/10/2025 at 12:50 PM and stated LPN #18 was terminated and reported to the state's Board of Nursing. The Assistant Director of Nursing (ADON) was interviewed on 09/12/2025 at 10:04 AM and stated when she was notified of the incident, she spoke with Resident #98, who stated LPN #18 informed them that the oxycodone was not available, yet it had been signed out as given by LPN #18. The ADON stated that after the incident all licensed nurses were required to receive education about drug diversion. She stated that all narcotic cards for residents cared for by LPN #18 were pulled, and interviews were completed with the residents she cared for to determine if other issues existed. The DON was interviewed on 09/12/2025 at 4:24 PM and stated when she notified of the incident, she began an investigation to include a review of the narcotic count log sheets, a count of the narcotics in the medication cart, interview and assessment of the resident, and interview with LPN #18. The DON stated that during the narcotic count, missing medications were identified and LPN #18 told her that she could not remember what happened, but that she had given the resident the medication. When narcotic count was completed, the DON stated she removed the keys to the medication cart from LPN #18, took LPN #18 to her office, and asked LPN #18 to write a statement. The DON stated a urine drug screen was obtained but was not valid due to the temperature of the urine and suspicion that the specimen was not urine. The DON stated LPN #18 was asked to submit another urine specimen for a drug screen but declined and exited the facility. The DON stated LPN #18 had not returned to the facility after 04/14/2025. The DON stated all narcotic logs were pulled in the entire facility, both west and east wings and no other discrepancies were found other than what LPN #18 had been involved with. Per the DON, for 12 weeks, each cart was audited to make sure narcotics were accurate, medications were signed out timely, and no further concerns were identified. The Administrator was interviewed 09/13/2025 at 12:45 PM and stated the DON notified her about the medication issue immediately. The Administrator stated she did not have a huge part in the investigation. An untitled, undated typed facility document indicated This will serve as our plan of abatement for [facility name] related to: Medication Error possible Drug diversion Allegation Details: Family states that a nurse did not give their [Resident #98] the prescribed PRN [pro re nata, as needed] pain medication and substituted with something else. The resident took a picture of the pills and sent to [his/her] [family member. The document indicated Upon Discovery on 4/14/25 the facility in accordance with our QAPI program leadership implemented the following corrective action measures: 4/14/25 During care conference with [Resident #98's] family the [family member] reported to SS [social services] Directed that [Resident #98] had sent [him/her] a picture of 2 pills [he/she] believed to be the night of 4/11/25 and stated the nurse gave [him/her] a Hydroxyzine and Tylenol while telling [him/her] she did not have any of [his/her] controlled pain medicine available. SSD immediately reported this to NHA [Nursing Home Administrator] and DON. 4/14/25 LPN was removed from medication assignment and interviewed by DON and ADON. Upon counting the cart with her it was discovered the count was off on 2 residents, [names]. The nurse's statement to the DON/ADON was that she had pulled the medications and had administered them. The residents denied receiving their medication nor had the LPN signed them out on the chain of custody from or on the MAR [medication administration record]. She was told she would be suspended pending investigation of the allegation. 4/14/25 LPN submitted a drug screen and the temperature would not read nor did the appearance of the liquid seem consistent with urine. She was asked to produce another sample and the LPN resigned on the spot. 4/14/25 - DON notified Police Dept of the possible diversions. As FRI [facility reported incident] was submitted to the Va [Virginia] DOH [Department of Health], LTC [long term care] ombudsman, APS [Adult Protective Services], and DHP [Department of Health Professions]. The provider and the RP [responsible party] of [Resident #98] was notified. 4/15/25 DON/Designee interviewed residents about care services including medication pass specific to not receiving and 1 resident [name] stated [he/she] never gets [his/her] meds [medications] at night when the 'black nurse with braids on top of her head in a ball works. This description matches that of the LPN who was suspended and has resigned. 4/14-4/15/25 Residents on LPNs assignment who are able to be interviewed were assessed for any change in condition that could have resulted from not receiving their prescribed medications. No identified findings. 4/15-4/17 the DON/Designee interviewed staff that worked the past 72 hours with LPN and asked about unusual behaviors of if they heard any complaints from the residents about care services - no negative findings. There was however a consistent theme of the LPN taking excessively long breaks. 4/17/25 HR [human resources]/designee reviewed the RN [registered nurse] [LPN] and 5 other random employees files to ensure that they were still in good standing to work at the facility - no negative findings. To identify other like residents: 4/15/25 DON/Designee interviewed residents about care services including medication pass specific to not receiving and 2 resident [names], stated [he/she] never gets [his/her] meds at night when the black nurse with braids on top of her head in a ball works. This description matches that of the LPN who was suspended and has resigned. 4/14-4/15/25 Residents on LPNs assignment who are able to be interviewed were assessed for any change in condition that could have resulted from not receiving their prescribed medications. No identified findings. To prevent this from recurring: The DON/Designee educated all licensed nurses on drug diversion and medication rights as well as notifying administrator in the event diversion is suspected. Completed by 4/21/25. All staff was re-educated on the abuse policy with emphasis on misappropriation - completed by 4/21/25. A systemic change was put in effect for use of the proper shift change controlled substance inventory count sheets. Any staff on PTO [paid time off]/vacation will be educated prior to working. All newly hired staff will be educated on said process during orientation. To Monitor and maintain ongoing compliance: The DON/Designee will audit random narcotic sheets to ensure that there is no s/s [signs/symptoms] of drug diversion weekly x 12 weeks. The DON/Designee will interview 3 random residents to ensure that they have no issues with not receiving pain medications weekly x 4 weeks then monthly x 2 months. The results of the audit will be forwarded to the facility QAPI [quality assurance performance improvement] committee for further review and recommendations. The facility completed an ad hoc QAPI meeting. Conclusion: [facility name] takes the care and services of our residents very seriously and continues to work diligently to ensure the safety of our residents. The facility completed all necessary steps for a sufficient correction action plan and met the requirements of past non-compliance as set forth by the State Operation Manual. We respectfully request you review our documentation and consider past noncompliance. Alleged POC [plan of correction]: 4/21/25. This document was signed by the Administrator, DON, ADON, East Unit Manager, [NAME] Unit Manger and SSD. The facility immediately implemented corrective actions after they became aware of the allegation. During the recertification survey conducted from 09/09/2025 to 09/13/2025, there was evidence the corrected actions had been implemented from 04/14/2025 to 04/21/2205 and there were no further concerns identified related to misappropriation of resident property. Staff and resident interviews revealed no concerns related to misappropriation of resident property. Observation of medication administration revealed no concerned related to misappropriation of resident property.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to permit a resident to return to the facility following hospitalization for one resident (Resident #3- R3), in a survey sample of four residents. The findings included: For R3, who was hospitalized , the facility staff failed to permit the resident to return and told the hospital they didn't have a bed available. On 3/12/25 and 3/13/25, a closed record review was conducted of R3's chart. According to the census information, R3 was admitted to the facility on [DATE]. R3 then discharged on 1/14/25 to the hospital and did not return. According to the census tab of the resident's chart and nursing progress notes, it noted that R3 was admitted to a semi-private room initially. Due to behavioral concerns, on 1/8/25, R3 was moved to a private room to be located closer to the nursing station, where he resided until his discharge on [DATE]. According to R3's discharge minimum data set (MDS) assessment, it indicated the resident discharged with return anticipated. There was no additional information within the clinical record regarding R3's status following discharge. On 3/12/25 at 2:57 p.m., an interview was conducted with the facility Administrator, who was handling admissions in the absence of an admissions director. The administrator was asked if the facility received a referral for admission for R3 following his hospitalization. The administrator reported they did receive a referral from the hospital on 1/15/25, and on 1/17/25 the facility accepted the referral. She went on to report that on 1/20/25, the admissions director let the hospital know they did not have a bed available. On 3/12/25 at 3:10 p.m., the administrator provided documentation of the communication between the facility and hospital regarding R3. Review of the document revealed that on 1/15/25, the facility received the referral. On 1/16/25 the facility requested additional information for review. On 1/17/25, the facility noted they would accept the resident. On 1/20/25, the facility noted, We are unable to accept at this time as we do not have a bed available at this time. The hospital discharge planner asked, When is the next bed? The facility responded, Will keep you updated in the AM on next bed available. Then on 1/30/25, the facility again noted, Will keep you updated on next available. On 2/6/25, the facility noted, Status changed to decline. Patient/Family declined or refused care. On 3/13/25, the facility census was reviewed which noted that on 1/20/25, the facility had 9 empty beds. According to the facility provided midnight census reports 1/21/24-2/5/25, the facility had empty beds each day and at no point were they at 100% capacity without a bed to accommodate R3. On 3/13/25 at 10:10 a.m., the surveyor met with the facility administrator again and explained that according to their midnight census report they did have beds available and asked for an explanation as to why the hospital was told they did not have a bed/room to accommodate R3. The administrator stated she would look into it and get back to the surveyor. On 3/13/25 at 11:22 a.m., the facility administrator reported to the surveyor that because R3 had been in a private room for isolation reasons the admissions director thought he needed to be readmitted to a private room. She provided a hand-written timeline of open private rooms following receipt of the referral of R3, which noted from 1/24/25-1/26/25, the facility did have a private room, but had no evidence this was communicated to the hospital. When asked if she had any evidence that R3 required a private room for isolation or that the hospital was asked about this, she stated she did not. The administrator explained that R3 had been moved to a private room the second day of his stay to be closer to the nursing station and that it was not for isolation reasons. The administrator stated she recalled that, now that the surveyor mentioned it. According to the facility's Bed Hold Notice, which read in part, . If you chose NOT to hold a bed: Your decision not to pay to have a bed held during your overnight absence will be treated as a voluntary discharge from the facility. You must remove (or make arrangements to have removed) all your personal belongings from the room that you were occupying. If you wish to be readmitted to the facility, then you must reapply for admission. If you are eligible for and require Medicare skilled nursing facility services or Medicaid nursing facility services, and your paid leave days for a calendar year have been exhausted, you will be entitled to readmission to the facility (i) if your previous room is available, or (ii) upon the first availability of a bed in a semi-private room or ward On 3/13/25 at approximately 11:30 a.m., the facility administrator was made aware that they lacked any evidence that R3 was offered readmission to the facility, in that they communicated to the hospital discharge planner that a bed was not available, when they did have beds available. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to have medication available for administration in accordance with physician orders for two residents (Resident #3-R3 and Resident #4-R4) in a survey sample of four residents. The findings included: 1. For R3, who missed three doses of IV antibiotic, the facility staff failed to notify the physician to afford the opportunity for alternate treatment orders to be administered. On 3/12/25, a closed record review was conducted of R3's chart. This review revealed that R3 was admitted to the facility on [DATE], from the hospitalization where he was diagnosed with severe sepsis. According to the hospital discharge summary, R3 was to continue Cefazolin 2 g, IV piggyback, every 8 hours Infectious disease was consulted during R3's hospitalization . The hospital discharge documentation also noted, . MSSA bacteremia. Initial blood cultures revealed MSSA bacteremia . The patient has been seen by infectious disease; the patient is to continue on cefazolin 2 g IV every 8 hours to complete 14 days with the last day being 1/8/2025 . According to the hospital medication administration record (MAR), R3's last dose of Cefazolin was administered on 1/7/25 at 10:37 a.m. According to the facility's MAR, R3 received the first dose of Cefazolin on 1/8/25 at 12 noon, resulting in the administration of only one dose on 1/7/25 and one dose on 1/8/25. According to the MAR, the nurse noted on 1/8/25 for the 4 a.m. dose, Med not available Provider and pharm [pharmacy] were made aware. According to the nursing note dated 1/8/25 at 4:39 a.m., it read, Patient's cefazolin, 2-gram, recon soln, intravenous order was not administered due to not unavailability [sic]. Provider and Pharm [pharmacy] aware and Pharm stated it will be delivered on the next run. There was no documentation regarding the doses missed on 1/7/25, or that the antibiotic was available in 1-gram dosing, to see if the physician wanted to give an alternate order. On 3/13/25 at 10:20 a.m., the director of nursing and regional director of clinical services met with the surveyor and presented a timeline of R3's antibiotic. According to the facility presented timeline, they noted R3 admitted on [DATE] at 1:52 p.m., per MD [medical doctor] discharge orders medication is to be completed on 1/8, Medication scheduled for 1/8/25 x 3 doses, 2 additional doses added to 1/9/25 to constitute the previous dose on 1/7/25 and 1/8/25. The facility provided a copy of the MAR for R3 which noted he received two doses of the antibiotic on 1/9/25. 2. For R4, who missed several consecutive doses of IV Cefazolin, the facility staff failed to notify the doctor. On 3/12/25, a clinical record review was conducted of R4's chart. This review revealed that R4 was admitted to the facility on [DATE]. According to the hospital discharge summary, R4 was hospitalized and treated for acute metabolic encephalopathy, Staphylococcus aureus bacteremia, and was noted with severe sepsis. The orders included, Cefazolin 2 g, IV piggyback every 8 hours. According to the medication administration record, R4 received the first dose of Cefazolin on 3/9/25 at 9 a.m., which was the second scheduled administration for that day. The notes indicated R4's two doses scheduled for 3/8/25, were not given with the notation, Not administered: drug/item unavailable comment: has not arrived from pharmacy. The first dose scheduled for 3/10/25 at 2 a.m., had the notation, rewritten. There was no indication that the doctor was made aware of the medication not being available, the missed doses, or given the opportunity to give alternate orders. On 3/12/25, in the afternoon, interviews were conducted with licensed practical nurses (LPN #1, LPN #2, and LPN #3). LPN #3 was the unit manager. Each of the three nurses explained that the pharmacy delivers twice daily. When asked what action is needed if a medication is not available for administration when it is due/scheduled, each of the nurses explained that the process is to call the doctor to make them aware and call the pharmacy to see where the medication is. On 3/12/25, in the afternoon, licensed practical nurse (LPN #1), explained that the pharmacy stocks an e-kit [emergency supply of medications] that is maintained at the facility. LPN #1 took the surveyor into the medication room and showed her a listing of items contained within the E-kit, which included Cefazolin, in a 1 gram vial, and that a quantity of 4 vials was maintained at the facility. Since the provider was not made aware of the doses that were not administered for R3 and R4, the physician was not given the opportunity to determine if he wanted the 1-gram doses to be administered nor was the physician given the opportunity to provide new orders with consideration of the 1-gram dose availability. On 3/12/25 at 3:24 p.m., during an interview with the director of nursing (DON), the DON stated that if orders are received by 10 a.m., they will not arrive at the facility until the next morning between 1 a.m. and 4 a.m. When asked, what the facility can do to ensure new admissions receive their medications, the DON went on to indicate that the facility can ask the hospital to administer medications due prior to the resident discharging, they can check the emergency supply of medications maintained at the facility and if it is not available there, they can notify the doctor and pharmacy, and have the medication STAT 'ed [urgently sent], but she added that is still a 4 hour window. The DON went on to say, The doctor can change it to something we have until the medication arrives. A facility policy titled, 7.0 Medication Shortages/Unavailable Medications was provided. According to the policy, which read in part, . 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the emergency medication supply. Facility staff should notify pharmacy and arrange for a STAT deliver, if medically necessary . 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain new orders or directions for alternate administration . No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to have medication available for administration in accordance with physician orders for two residents (Resident #3-R3 and Resident #4-R4) in a survey sample of four residents. The findings included: 1. For R3, the facility staff failed to have intravenous (IV) Cefazolin (an antibiotic) available to administer as ordered by the physician. On 3/12/25, a closed record review was conducted of R3's chart. This review revealed that R3 was admitted to the facility on [DATE], from the hospitalization where he was diagnosed with severe sepsis. According to the hospital discharge summary, R3 was to continue Cefazolin 2 g, IV piggyback, every 8 hours . Infectious disease was consulted during R3's hospitalization . The hospital discharge documentation also noted, . MSSA bacteremia. Initial blood cultures revealed MSSA bacteremia . The patient has been seen by infectious disease; the patient is to continue on cefazolin 2 g IV every 8 hours to complete 14 days with the last day being 1/8/2025 . According to the hospital medication administration record (MAR), R3's last dose of Cefazolin was administered on 1/7/25 at 10:37 a.m. According to the facility's MAR, R3 received the first dose of Cefazolin on 1/8/25 at 12 noon. R3 missed two doses on 1/7/25 and one dose on 1/8/25. According to the MAR, the nurse noted on 1/8/25 for the 4 a.m. dose, Med not available Provider and pharm [pharmacy] were made aware. According to the nursing note dated 1/8/25 at 4:39 a.m., it read, Patient's cefazolin, 2-gram, recon soln, intravenous order was not administered due to not unavailability [sic]. Provider and pharm [pharmacy], aware and Pharm stated it will be delivered on the next run. There was no documentation that reflected the missed doses of IV antibiotic on 1/7/25. On 3/12/25, in the afternoon, interviews were conducted with licensed practical nurses (LPN #1, LPN #2, and LPN #3). LPN #3 was the unit manager. Each of the three nurses explained that the pharmacy delivers twice daily, and they have a process for STAT [emergent] medications to be delivered as well. They explained when an admission is coming in, they enter the orders into the electronic health record as early as they can, which also transmits to the pharmacy, so that the pharmacy can send the medications to the facility. When asked if a medication is not available for administration when it is due/scheduled, each of the nurses explained that the process is to call the doctor to make them aware and call the pharmacy to see where the medication is. On 3/12/25 at 2:18 p.m., a phone call was placed to the facility's contracted pharmacy. According to the pharmacy representative, R3's Cefazolin order was received in the pharmacy on 1/7/25 and filled for 6 bags/doses. It was delivered to the facility on [DATE] at 2:41 a.m. The pharmacy representative also confirmed that the pharmacy delivers to the facility twice daily. On 3/12/25 at 3:24 p.m., during an end of day meeting, the facility administrator, director of nursing, and regional director of clinical services, were made aware of the above findings and the concern that R3 missed multiple doses of IV antibiotic due to the medication being unavailable. On 3/13/25 at 10:20 a.m., the director of nursing and regional director of clinical services met with the surveyor and presented a timeline of R3's antibiotic. According to the facility presented timeline, they noted R3 admitted on [DATE] at 1:52 p.m., per MD [medical doctor] discharge orders medication is to be completed on 1/8, Medication scheduled for 1/8/25 x 3 doses, 2 additional doses added to 1/9/25 to constitute the previous dose on 1/7/25 and 1/8/25. 2. For R4, the facility failed to have IV Cefazolin available for administration as per physician orders. On 3/12/25, a clinical record review was conducted of R4's chart. This review revealed that R4 was admitted to the facility on [DATE]. According to the hospital discharge summary, R4 was hospitalized and treated for acute metabolic encephalopathy, Staphylococcus aureus bacteremia, and was noted with severe sepsis. The orders included, Cefazolin 2 g, IV piggyback every 8 hours. According to the medication administration record, R4 received the first dose of Cefazolin on 3/9/25 at 9 a.m., which was the second scheduled administration for that day. the notes indicated R4's two doses scheduled for 3/8/25, were not given with the notation, Not administered: drug/item unavailable comment: has not arrived from pharmacy. The first dose scheduled for 3/10/25 at 2 a.m., had the notation, rewritten. On 3/12/25 at 2:18 p.m., a telephone call was placed to the facility's contracted pharmacy. When asked about R4's Cefazolin, the pharmacy reported they received the order and keyed it on 3/8/25 and said, it manifested at 7:07 p.m., and was set-up to go on the 11 o'clock p.m. run that evening. The pharmacy indicated they didn't have any details regarding when it was actually delivered to the facility but knew the delivery driver picked it up from the pharmacy at 3:30 a.m., on 3/9/25. On 3/12/25, in the afternoon, interviews were conducted with licensed practical nurses (LPN #1, LPN #2, and LPN #3). LPN #3 was the unit manager. Each of the three nurses explained that the pharmacy delivers twice daily, and that they have a process for STAT [emergent] medications to be delivered as well. They explained when an admission is coming in, they enter the orders into the electronic health record as early as they can, which also transmits to the pharmacy, so that the pharmacy can send the medications to the facility. When asked about needed action if a medication is not available for administration when it is due/scheduled, each of the nurses explained that the process is to call the doctor to make them aware and call the pharmacy to see where the medication is. On 3/12/25 at 3:24 p.m., during an end of day meeting with the facility administrator, director of nursing (DON), regional director of clinical services (RDCS), the above findings were discussed. The DON stated that if orders are received by 10 a.m., they will not arrive at the facility until the next morning between 1 a.m. and 4 a.m. When asked, what the facility can do to ensure new admissions receive their medications, the DON stated that the facility can ask the hospital to administer medications due prior to the resident discharging, they can check the emergency supply of medications maintained at the facility and if it is not available there, they can notify the doctor and pharmacy and have the medication STAT 'ed [urgently sent], but that is still a 4 hour window. She went on to say, The doctor can change it to something we have until the medication arrives. On 3/13/25 at 9:50 a.m., R4 was visited in his room. A family member, who identified themselves as the resident's daughter was at the bedside. R4 was asked about medications and if he had any delay in receiving medications or missed any doses, the resident stated that they were not aware, but the family member reported that R4 had confusion and was not reliable in recall of events. On 3/13/25 at 10:20 a.m., the DON and RDCS presented the surveyor with a timeline they had prepared regarding R4's IV antibiotic. The timeline read, Missed 2 doses on 3/8/ and 3/9, stated pharmacy delivered medication at 330a.m on 3/9/25 . admitted on [DATE] at 1234 p.m., Ordered for Cefazolin 2gm IV q8hrs [every 8 hours]. 3/8/25 at 1800 [6pm] nursing charted against order, Medication not here from pharmacy. 3/9 at 2 a.m., nursing charting against the rewritten order documented .the medications changed to be administered at 9am, 5 pm, and 1 am. (nurse states she was unaware she didn't unpack mediation right when they were delivered.) Medication arrived from the pharmacy at 330 am, Next dose at 9am moving forward administered. Additional doses added to residents abx [antibiotic] regimen when noticed. [sic] The facility policy titled, 4.0 Authorization and Communication of Orders was provided and reviewed. According to the policy, it read in part, .10. Facility should verify transfer/transition and admission orders with the resident's physician/prescriber before they are communicated to the pharmacy. 10.1 Once admission orders are verified, staff should promptly transmit medication orders to the pharmacy. A delay in transmission of new orders to the pharmacy may impact the time of delivery and resident access to medically necessary medications . A facility policy titled, 7.0 Medication Shortages/Unavailable Medications was provided. According to the policy, which read in part, . 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the emergency medication supply. Facility staff should notify pharmacy and arrange for a STAT deliver, if medically necessary . 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain new orders or directions for alternate administration . No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents were free from significant medication errors, resulting in multiple missed doses of intravenous (IV) antibiotics for two residents (Resident #3- R3 and Resident #4-R4) in a survey sample of four residents. The findings included: 1. For R3, who was ordered IV Cefazolin by an infectious disease doctor for treatment of MSSA [methicillin-susceptible Staphylococcus aureus] bacteremia, the resident missed three consecutive doses. On 3/12/25, a closed record review was conducted of R3's chart. This review revealed that R3 was admitted to the facility on [DATE], from the hospitalization where he was diagnosed with severe sepsis. According to the hospital discharge summary, R3 was to continue Cefazolin 2 g, IV piggyback, every 8 hours . Infectious disease was consulted during R3's hospitalization . The hospital discharge documentation also noted, . MSSA bacteremia. Initial blood cultures revealed MSSA bacteremia . The patient has been seen by infectious disease; the patient is to continue on cefazolin 2 g IV every 8 hours to complete 14 days with the last day being 1/8/2025 . According to the hospital medication administration record (MAR), R3's last dose of Cefazolin was administered on 1/7/25 at 10:37 a.m. According to the facility's MAR, R3 received the first dose of Cefazolin on 1/8/25 at 12 noon. R3 missed two doses on 1/7/25 and one dose on 1/8/25. According to the MAR, the nurse noted on 1/8/25 for the 4 a.m. dose, Med not available Provider and pharm [pharmacy] were made aware. According to the nursing note dated 1/8/25 at 4:39 a.m., it read, Patient's cefazolin, 2-gram, recon soln, intravenous order was not administered due to not unavailability [sic]. Provider and pharm [pharmacy], aware and Pharm stated it will be delivered on the next run. On 3/12/25 at 2:18 p.m., a phone call was placed to the facility's contracted pharmacy. According to the pharmacy representative R3's Cefazolin order was received in the pharmacy on 1/7/25 and filled for 6 bags/doses. It was delivered to the facility on [DATE] at 2:41 a.m. The pharmacy confirmed they deliver to the facility twice daily and have a process for STAT [emergent] medications. On 3/12/25 at 2:40 p.m., an interview was conducted with a registered nurse (RN #1). When asked about antibiotics, RN #1 said, You cannot miss a dose and have to take all of the antibiotics. RN#1 replied, Usually when a dose is missed you take it as soon as you realize it. When asked why you can't miss doses, RN #1 said, Because it [the infection] can try to work against the antibiotic and build up resistance. When asked what the risk is of someone missing a few doses in the middle of a course of antibiotics is, RN #1 said, It's a big risk. You have to talk to the doctor and may have to extend the treatment. You can't miss a dose of antibiotics at all. On 3/12/25 at 2:47 p.m., an interview was conducted with a licensed practical nurse (LPN #3), who identified as the unit manager. When asked about antibiotic use and missed doses, LPN #3 said, When someone has an infection, they have to finish the course of antibiotics unless the doctor says otherwise. When asked what the risk is, if someone misses doses of antibiotics, LPN #3 said, You risk the infection growing and long-term can become resistant to antibiotics all together. When asked what action is needed if an antibiotic is not available for administration, LPN #3 said, We call the pharmacy to see if we can get it STAT 'ed to us and notify the doctor to see if they want to change the orders. On 3/13/25 at 10:20 a.m., during an interview with the director of nursing (DON) and regional director of clinical services (RDCS), the DON reported, It is an understanding by doctor [name redacted] if missed doses, we add to the end. When asked if this is an acceptable course of treatment for infections, the DON said, I have identified some opportunities. When asked if this is in accordance with the facility's antibiotic stewardship program and if adding doses to the end of the course of treatment is the acceptable thing to do, the DON said, No. On 3/13/25 at 11:06 a.m., an interview was conducted with a registered nurse, who was the facility's infection preventionist (IP). During the interview with the IP she mentioned, It is an understanding with the provider that antibiotic doses are added to the end of the course of treatment for missed doses. When asked why someone would miss doses, the IP explained, Our pharmacy is in Richmond. We have a backup box, but if it is not available in the back-up box we communicate to the doctor. When asked why it is important for someone to receive all the doses of an antibiotic, the IP said, Because it is treating an infection, and it is ordered by the doctor. When asked to explain any risks related to missing doses during treatment with antibiotics, the IP explained that It [the infection] could create a resistance to the antibiotic, it may not treat the infection appropriately [because therapeutic levels are not maintained]. When asked how often this happens, the IP said, Here lately it has been more, since we switched pharmacies. We had [pharmacy name redacted] here in [local city name redacted] but that closed and our cut off times have changed. We have had a good amount of IV antibiotics, but I feel like it has happened more than it did in the past. When asked if she had talked to the medical director and/or pharmacy about reviewing the contents and quantity of the emergency supply of medications maintained in house, the IP said, When the unit manager notified me. We have 1 gram of Ceftin versus the 2 grams. We had discussed talking to the pharmacy about the amount of antibiotics we have in the back-up box. When asked if that conversation had been held, the IP stated, No. When asked if a meeting had been scheduled, the IP said, No. According to the facility policy titled, Antimicrobial Stewardship Program Policy, which read in part, As a component of the monthly infection prevention and control committee (IPCC) meeting the facility's use of antibiotics will be reviewed to include: monitoring/tracking of antibiotic prescribing, use, and resistance in order to promote a culture of optimal antibioitic use within the facility . The policy did not address missed doses of antibiotic treatment. On 3/13/25, the facility administrator, director of nursing and regional director of clinical services were made aware of the above findings. No additional information was provided.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide specialized rehabilitative services as required in the plan of care for one of five residents in the survey sample (Resident #1). The findings include: For five weeks, Resident #1 was not provided occupational and physical therapy as ordered by the physician and as required in her rehabilitation plan of treatment. Resident #1 was admitted to the facility with diagnoses that included left foot abscess, lower limb cellulitis, lymphedema, cerebral palsy, pressure ulcer and morbid obesity. The minimum data set (MDS) dated [DATE] assessed Resident #1 as cognitively intact. Resident #1's clinical record documented physician orders dated 9/9/22 for physical therapy (PT) and occupational therapy (OT), both at five to seven times per week for up to 12 weeks to meet plan of care requirements. Resident #1's physical therapy plan of treatment dated 9/9/22 documented treatment approaches that included therapeutic exercises, neuromuscular re-education, manual therapy techniques, and therapeutic activities, with goals targeted around mobility improvement so the resident could return home. Resident #1's OT plan of treatment dated 9/9/22 documented treatment approaches that included therapeutic exercises, self-care training, and wheelchair management, with goals targeted around dressing, toileting, propelling in wheelchair, and bathing. The OT and PT plans documented the frequency of treatment/services as five to seven times per week for 12 weeks. Resident #1's therapy records revealed the following weeks that PT and/OT services were not provided as ordered during September 2022 and October 2022: 9/25/22 through 10/1/22 - 4 PT sessions, 2 OT sessions 10/2/22 through 10/8/22 - 2 PT sessions, 2 OT sessions 10/9/22 through 10/15/22 - 2 PT sessions 10/16/22 through 10/22/22 - 3 PT sessions 10/23/22 through 10/29/22 - 3 PT sessions On 6/29/23 at 11:00 a.m., the current rehab director (other staff #1) was interviewed about the 17 therapy sessions that were not provided to Resident #1 as ordered. The rehab director stated that during September/October 2022, there were some missed therapy visits because they were missing one LPTA (licensed physical therapy assistant). The rehab director stated there were two LPTA's at that time, with one LPTA serving as the director of rehab. The rehab director stated one LPTA left around the end of September 2022 without notice. The rehab director stated, It was hard to meet the needs with one LPTA. On 6/29/23 at 11:41 a.m., the LPTA (other staff #2) who was serving as rehab director in September/October 2022 was interviewed, along with the current rehab director (other staff #1) and the administrator. The LPTA stated they had only two LPTA's at that time and one LPTA left at the end of September 2022, leaving one LPTA for the building. The LPTA stated that she provided services to Resident #1 at times and Resident #1 .sometimes refused. The current rehab director stated standard staffing included at least two LPTA's, a physical therapist, occupational therapist, speech therapist and one to two COTA's (certified occupational therapy assistants). On 6/29/23 at 12:30 p.m., the current rehab director stated that after viewing the therapy records, Resident #1 was documented as refusing therapy during on 9/19/22 and 10/24/22. When questioned about the other missing therapy sessions, the current rehab director stated that one of the two LPTA's left without notice on 9/23/22, leaving one LPTA who was also serving as the director of rehab. The rehab director stated that staff were pulled from other facilities, worked overtime, and agency staff were also utilized. The rehab director stated that sometimes staff scheduled to fill-in did not show up. The administrator stated that the therapy session frequency for Resident #1 was not as ordered, but Resident #1's stay was extended as progress continued in meeting therapy goals, eventually resulting in the discharge to home. This finding was reviewed with the administrator on 6/29/23 at 12:45 p.m. No other information about Resident #1's missed therapy sessions was provided prior to the end of the survey.

Based on observation, resident interview, staff interview, facility policy review and clinical record review, the facility staff failed to provide food items per the menu and/or meal ticket for two of eighteen residents in the survey sample, Resident #29 and #32. Resident #29 and 32 were not routinely provided food per their meal ticket or as listed on the menu. The findings include: 1. Resident #29 was admitted to the facility with diagnoses that included [CONDITION(S)] ([CONDITION(S)]), diabetes, [CONDITION(S)], chronic kidney disease, [CONDITION(S)], anxiety, [CONDITION(S)], [CONDITION(S)], hypertension, and [CONDITION(S)]. The minimum data set (MDS) dated [DATE] assessed Resident #29 as cognitively intact. On 6/14/22 at 11:58 a.m., Resident #29 was interviewed about quality of life/care in the facility. Resident #29 stated that he did not get drinks and/or food items as listed on the meal ticket and this happened on a routine basis. Resident #29 stated he was supposed to get a diet ginger ale or cola on each meal tray and he frequently did not receive the cola. The resident stated bread items like rolls and/or toast were not routinely provided with meals. On 6/14/22 at 12:30 p.m., Resident #29 was observed with his lunch tray. The lunch ticket dated 6/14/22 documented the resident's order as regular, thin liquids with standing orders of 4 ounces whole milk, 4 ounces diet cola, a grilled cheese sandwich with tomato and mayonnaise and an alert listed as send extra vegetables. The resident's lunch tray had pork bites on rice, double portion of corn, milk and a diet cola. There was no grilled cheese sandwich with tomato/mayonnaise as listed on the meal ticket and no other bread of any type. On 6/15/22 at 8:28 a.m., Resident #29 was served breakfast in his room. The meal ticket listed food items as 4 ounces of whole milk, 4 ounces of orange juice, 4 ounces diet cola, 1 cup cold cereal, 8 ounces oatmeal and 1/2 cup scrambled eggs. The resident's breakfast tray had no diet cola, no cold cereal and no toast/bread. The resident stated the serving of scrambled eggs was very small and he would prefer some type of meat and toast. Resident #29 stated he hated to ask for food/drink items that were not on his tray. The resident stated by the time the requested items were served he was done with eating. The resident stated not getting food/drink items on his tray happened almost every day. Resident #29 stated butter was frequently on his tray but bread was rarely provided. The facility's regular menu/diet spreadsheet for 6/14/22 included an English muffin for breakfast but no bread for the lunch and dinner meal. The menu/diet spreadsheet for breakfast on 6/15/22 listed toast and/or a biscuit was supposed to be served in addition to juice, cereal, scrambled eggs with cheese, milk and coffee or tea. On 6/15/22 at 8:35 a.m., the dietary manager (other staff #1) and the registered dietitian (RD - other staff #2) were interviewed about Resident #29's food concerns and not getting food/drink items as listed on the meal ticket. The dietary manager stated the grilled cheese sandwich and the diet cola must have been omitted in error from the tray line. The dietary manager stated rolls, bread and/or toast were routinely available for residents. The RD stated the meal tickets did not print the day to day menu but included the resident's preferences. The dietary manager stated all of the preferences don't show on the meal tickets. The dietary manager stated he was not familiar with the meal ticket printing system and was working to figure it out. The dietary manager stated again the staff on the tray line did not plate the resident's food according to the ticket and that residents should be getting rolls, bread and/or toast with meals. The RD stated the facility followed the corporate menus. Resident #29's clinical record documented a physician's order dated a 7/20/21 for a regular diet with thin liquids. The resident's plan of care (revised 3/8/22) listed the resident had increased nutrition/hydration risks due to [CONDITION(S)], [CONDITION(S)] and use of multiple diuretics. Interventions to support acceptable lab values included, .Provide diet per order .Respect resident dietary choices, likes Diet Coke, 2% milk . The facility's policy titled Menu Planning Policy (revised 7/27/20) documented, .Based on a facility's reasonable efforts, menus will reflect the religious, cultural, and ethnic needs of the resident population, as well as individual resident and resident groups . This finding was reviewed with the administrator and director of nursing during a meeting on 6/15/22 at 11:15 a.m. 2. Resident # 32 was admitted with diagnoses that included end stage renal disease, [CONDITION(S)], coronary artery disease, hypertension, [CONDITION(S)], peripheral disease, gastroesophageal reflux disease, diabetes mellitus, [CONDITION(S)], arthritis, [CONDITION(S)] with right sided [CONDITION(S)], [CONDITION(S)] disorder, dysphagia, hypertrophy, [CONDITION(S)], [CONDITION(S)], and generalized muscle weakness. According to an Annual Minimum Data Set with an Assessment Reference Date of 4/27/2022, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 05 out of 15. At 12:20 p.m. on 6/14/2022, during observation of lunch in the main dining room, the resident was observed at a table, seated in a wheelchair. The lunch tray was placed in front of Resident # 32 and set-up for eating. The entree on the resident's tray consisted on pork bites over rice, multi-colored green beans, and a grilled cheese sandwich. Resident # 32 picked up a pork bite with her fingers and placed it in her mouth. After eating the pork, the resident made a face and pushed the tray away. Asked if there was something wrong, Resident # 32 mumbled No good. Asked about getting a substitute meal, Resident # 32 declined to ask for one. Review of the meal ticket on Resident # 32's meal tray revealed the following: Standing Orders: > 3 oz (ounce)/2 sl Deli Sandwich (5 slices meat). There was no deli sandwich on Resident # 32's meal tray. At 8:50 a.m. on 6/15/2022, the Dietary Manager was interviewed regarding standing orders on the meal tickets. According to the Dietary Manager, residents .should get the standing order item and the main menu meal items. When told Resident # 32 got a grilled cheese sandwich instead of a deli sandwich, the Dietary Manager said the grilled cheese sandwich was not a deli sandwich, and the resident should have gotten the deli sandwich. The findings was discussed during a meeting at 11:15 a.m. on 6/15/2022 that included the Administrator, Director of Nursing, and the survey team.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to implement a physician's order for one of eighteen residents in the survey sample, Resdient #29. Resident #29's physician ordered eye drops were not administered for three weeks. The findings include: Resident #29 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), diabetes, congestive heart failure, chronic kidney disease, bipolar disorder, anxiety, atrial fibrillation, insomnia, hypertension, and osteoporosis. The minimum data set (MDS) dated [DATE] assessed Resident #29 as cognitively intact. On 6/14/22 at 11:58 a.m., Resident #29 was interviewed about quality of care in the facility. Resident #29 stated he had seen an eye doctor several weeks ago who prescribed eye drops but he was not receiving the drops. Resident #29 stated he was supposed to get eye drops about four to five times per day to help with eye irritation. Resident #29's eyes were observed at this time with redness noted on edges of the upper and lower lids. Resident #29's clinical record documented a physician's order dated 5/24/22 for, Preservative free tears 1 drop both eyes 6 times a day . The clinical record documented a nursing note dated 5/25/22 at 9:35 a.m. stating, Resident seen by (eye physician). new order for artificial tears 1 drop to both eyes 6x (times per) day . Resident #29's medication administration record (MAR) for May 2022 and June 2022 documented no entries for the preservative-free eye drops. The clinical record documented no administration of the eye drops from 5/24/22 through 6/14/22 as ordered. On 6/15/22 at 9:17 a.m., the registered nurse (RN #3) administering medications to Resident #29 was interviewed about the eye drops. RN #3 stated she was not aware of an order for scheduled eye drops for Resident #29 and the MAR had no order listed for the drops. On 6/15/22 at 9:20 a.m., the unit manager (RN #1) was interviewed about Resident #29's eye drops. After reviewing the clinical record, RN #1 stated the order for the preservative-free eye drops was not entered into the health record and the order did not show on the MAR for administration. RN #1 stated the floor nurse receiving the order was responsible for initiating the order for the medication. Resident #29's plan of care (revised 3/8/22) documented the resident had potential for eye irritation due to dry eyes. Interventions to decrease and/or eliminate eye irritation and dry eyes included, Instill/apply eye medication as per physician orders .Obtain eye exam consultation as needed . This finding was reviewed with the administrator and director of nursing during a meeting on 6/15/22 at 11:15 a.m.

Based on medication pass and pour observation, staff interview, and facility document review, the facility failed to ensure medications were available for one of 18 residents in the survey sample, Resident #32. Resident #32's Omeprazole10 milligrams (for reflux) was not available for administration. The Findings Include: Resident #32 was admitted with diagnoses which included: End stage renal failure, reflux, peripheral vascular disease, and diabetes. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 4/27/22. Resident #32's cognitive score was a 5 indicating severely impaired cognitively. On 06/15/22 at 8:04 AM, a medication pass and pour observation was conducted. Resident #32's Omeprozole 10 milligrams was ordered to be given at 9:00 AM. Registered nurse (RN #2) could not find Resident #32's Omeprozole in the medication cart. RN #2 stated that the medication was not available over the counter (because of the dosage) and had to be ordered through the pharmacy. RN #2 stated that pharmacy was going to send the medication later in the day. On 06/15/22 at 10:36 AM, the director of nursing (DON) was interviewed regarding reordering medications through the pharmacy. The DON stated medications should be reordered when a resident gets down to a three day supply. The physician's order for Resident #32's Omeprozole documented, Omeprozole Tablet 10 MG (milligrams) by mouth in the morning .dispense 9:00 AM. The facility policy, Ordering and Receiving Non-Controlled Medications, documented .Reorder medications based on the estimated refill date on the pharmacy RX (prescription) label, or at least three days in advance to ensure an adequate supply is on hand . On 06/15/22 at 11:22 AM, the above finding was presented to the director of nursing, administrator, and nurse consultant. No other information was presented prior to exit conference on 6/15/22.

Based on medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate less than 5 percent. There were two errors out of 38 opportunities resulting in a medication error rate of 5.26 percent. The Findings Include: On 06/15/22 at 8:04 AM a medication pass and pour observation was conducted with RN #2. Resident #32's Omeprozole 10 milligrams was ordered to be given at 9:00 AM. Registered nurse (RN #2) could not find Resident #32's Omeprozole in the medication cart. RN #2 said that the medication was not available over the counter (because of the dosage) and had to be ordered through the pharmacy. RN #2 stated that pharmacy was going to send the medication later in the day. The physician's order for Resident #32's Omeprozole documented, Omeprozole Tablet 10 MG (milligrams) by mouth in the morning .dispense 9:00 AM. RN #2 began pulling medications to be given to Resident #44. One of the medications was labeled, Propranolol 40 MG give one tablet . RN #2 then popped the Propranolol into a medicine cup along with other medications and gave the medications to Resident #44. After the medication observation was complete, all the medications given by RN #2 were then reconciled with the physician's orders. Resident #44's Propranolol order read Propranolol Tablet 20 MG give one tablet by mouth . On 06/15/22 at 9:05 AM, the order was reviewed with RN #2. RN #2 then pulled the medication given (Propranolol 40 MG) from the medication cart and realized that she had given the wrong dose. After looking at all of Resident #44's medications, RN #2 found the correct dose of Propranolol and said the 40 MG dose of Propranolol shouldn't have been on the cart for distribution. On 06/15/22 at 11:22 AM, the above finding was presented to the director of nursing, administrator, and nurse consultant. No other information was presented prior to exit conference on 6/15/22.

Based on observation, staff interview and facility document review, the facility staff failed to follow infection control protocols regarding hand hygiene. A staff member failed to perform hand hygiene between resident contacts during a dining observation on 6/14/22. The findings include: A dining observation was conducted in the main dining room on 6/14/22 starting at 12:40 p.m. Resident #30, seated at a table near the center of the room, attempted to take his shirt off during the meal service. Certified nurses' aide (CNA) #1 assisted Resident #30 with putting his shirt back on. Without hand hygiene, CNA #1 then retrieved a lunch tray from the cart and served a tray to another resident. CNA #1 set up the meal tray touching the utensils, wrapped cookie and drinking glass. CNA #1 proceeded to provide assistance with tray service and meal set-up to three additional residents. CNA #1 touched the resident's tray, utensils, applied seasonings, opened milk cartons, discarded trash and placed thermal tops on the counter. CNA #1 performed no hand hygiene between any of these residents or after contact with the utensils and/or food items. On 6/14/22 at 12:47 p.m., CNA #1 was interviewed about hand hygiene. CNA #1 stated she was supposed to use hand sanitizer between residents. CNA #1 stated, I was just trying to keep him (Resident #30) from stripping. CNA #1 stated hand sanitizer was available on the meal carts and in the dining room. The facility's policy titled Hand Hygiene/Handwashing Policy (revised 7/14/21) documented, Hand washing is the most important component for preventing the spread of infection .Perform hand hygiene .Before and after having direct contact with residents .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident .Wash hands with either plain or antimicrobial soap and water or rub hands with an alcohol-based formulation before handling medication and preparing food . This finding was reviewed with the administrator and director of nursing during a meeting on 6/15/22 at 11:15 a.m.

Based on staff interview and clinical record review, the facility staff failed to develop comprehensive care plans for eleven of 22 residents in the survey sample, Resident #'s 10, 17, 33, 39, 5, 12, 31, 18, 8, 301, and 11. Resident #10 had no care plan developed for activities of daily living, incontinence, falls, nutrition, pressure ulcer prevention, psychoactive medication use, pain management, [CONDITION(S)], fluid intake restrictions or [CONDITION(S)]. Resident #17 had no care plan developed for activities of daily living, incontinence, falls, dehydration, dental problems, pressure ulcer prevention or [CONDITION(S)] medication use. Resident #33 had no care plan developed to address communication, activities of daily living, incontinence, falls, nutrition, dehydration or psychoactive medication use. Resident #39 had no care plan developed to address hospice care. Resident #5 had no care plan developed for activities of daily living, communication, nutrition, falls, dehydration and pressure ulcers. Resident #12 had no care plan developed for impaired range of motion, positioning or fall prevention. Resident #31 had no care plan developed for fall prevention, skin integrity or [CONDITION(S)] care. Resident #18 had no care plan developed for dental problems, nutrition or weight loss. Resident #8 had no care plan developed for hospice care and skin integrity. Resident #301 had no care plan developed regarding an indwelling urinary catheter. Resident #11 had no care plan developed regarding communication, incontinence, falls, nutrition, pressure ulcers or hospice care. The findings include: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #10 as cognitively intact. The admission MDS dated [DATE] documented Resident #10 required the extensive assistance of one person for bed mobility/transfers and activities of daily living. This MDS listed the resident had poor balance, had occasional bladder incontinence, occasional pain and had experienced a fall with no injury. The care area assessment summary section triggered the following care areas as requiring a comprehensive plan of care: cognitive loss, activities of daily living, incontinence, falls, nutrition, pressure ulcers, psychoactive medication use, pain and plan to return to community. The facility documented a care plan would be developed for each triggered care area. Resident #10's clinical record documented physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes documented the resident's medications were changed on 2/21/21 to address increased [CONDITION(S)] pain and continued inability to sleep well at night. Resident #10's plan of care (dated 1/29/21) included no problems, goals and/or interventions regarding hemodialysis, nutrition, fluid intake restriction, activities of daily living, incontinence, fall prevention, pressure ulcer prevention, psychoactive medication use, pain management or [CONDITION(S)]. On 2/24/21 at 8:26 a.m., the registered nurse (RN #1) responsible for care plans was interviewed about Resident #10's plan. RN #1 stated, I don't have a full care plan for [Resident #10]. RN #1 stated she was behind on care plans. On 2/24/21 at 9:00 a.m., RN #1 was interviewed again about Resident #10. RN #1 stated Resident #10's care plan had not been completed. RN #1 stated the care plan was discussed but not done. RN #1 stated, I got behind and could not catch up. This finding was reviewed with the administrator and director of nursing during a meeting on 2/24/21 at 4:00 p.m. 2. Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #17 with moderately impaired cognitive skills. The annual MDS dated [DATE] documented Resident #17 required set-up help for activities of daily living and toileting, assistance for balance during transitions or when walking, was occasionally incontinent of bladder, frequently incontinent of bowel, had missing teeth and had experienced a recent unplanned weight loss. The care area assessment summary triggered the following care areas as requiring a care plan: cognitive loss; activities of daily living; incontinence; falls; nutrition; dehydration; dental; pressure ulcer prevention and psychoactive medication use. The facility documented a care plan would be developed for each triggered care area. Resident #17's plan of care (revised 3/23/2) included no problems, goals and/or interventions to address activities of daily living, incontinence, falls, dehydration, dental concerns, pressure ulcer prevention or the resident's use of psychoactive medications. A nutrition care plan listed the resident was prescribed a therapeutic diet and had difficulty chewing but made no mention of an actual weight loss. On 2/24/21 at 8:26 a.m., the registered nurse (RN #1) responsible for MDS and care plan development was interviewed about Resident #17. RN #1 stated she was behind developing and updating care plans. RN #1 stated Resident #17's care plan was not complete and stated, What's in the computer is all there is. This finding was reviewed with the administrator and director of nursing during a meeting on 2/24/21 at 4:00 p.m. 3. Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #33 as cognitively intact. This MDS listed the resident required the extensive assistance of two people for bed mobility/transfers and required the extensive assistance of one person for activities of daily living. The MDS assessed the resident with behaviors not directed toward others, occasional bowel incontinence, bladder incontinence and occasional pain. The care area assessment summary of the admission MDS dated [DATE] triggered the following care areas as requiring a comprehensive care plan: cognitive loss, communication, activities of daily living, incontinence, psychosocial needs, mood, behaviors, recreational activities, fall prevention, nutrition, dehydration and psychoactive medication use. The facility documented a care plan would be developed for each triggered care area. Resident #33's plan of care (revised 2/24/21) included no problems, goals and/or interventions for communication, activities of daily living, incontinence, fall prevention, nutrition, dehydration and psychoactive medication use. On 2/24/21 at 8:26 a.m., the registered nurse (RN #1) responsible for care plan development was interviewed about Resident #33. RN #1 stated she was behind on care plans and she had not completed a comprehensive care plan for Resident #33. On 2/24/21 at 9:00 a.m., RN #1 stated Resident #33's plan of care had been discussed by the interdisciplinary team but had not been documented. RN #1 stated, I got behind and could not catch up. This finding was reviewed with the administrator and director of nursing during a meeting on 2/24/21 at 4:00 p.m. 4. Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #29 as severely impaired for daily decision making with fluctuating periods of inattention and disorganized thinking. Under Section G - Functional Status, Resident #39 was assessed as total dependent for all activities of daily living (ADLs) including transfers, toileting, bed mobility, locomotion, hygiene, bathing, eating, and dressing. Under Section O - Special Treatments, Procedures and Programs, Hospice was checked as yes for receiving services. On 2/24/2021 Resident #29's clinical record was reviewed. Observed on the order summary (physician orders) was the following order: Refer for hospice consult. Family chooses [Service Provider]. 01/22/2021. Observed in the Miscellaneous Tab was hospice documentation noting Resident #39 was admitted to hospice on 01/26/2021. On 02/24/2021 at 2:42 p.m., the MDS Coordinator (RN #1) was interviewed regarding the hospice care plan. RN #1 stated the significant change assessment dated [DATE] was completed because Resident #39 was admitted to hospice on 01/26/2021. RN #1 stated, I missed the hospice care plan, it was an oversight. I am having a care plan meeting tomorrow and will discuss updates and get it done then. On 02/24/2021 at 3:45 p.m. the administrator, DON (director of nursing), and corporate consultant were informed of the above findings during a meeting. No other information was received by the survey team prior to exit on 02/25/2021 at 11:45 a.m. 5. Resident # 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #5 as severely impaired for daily decision making with a score of 7 out of 15 with fluctuating periods of disorganized thinking. Under Section G - Functional Status, Resident #5 was assessed as extensive assistance for transfers, toileting, locomotion, bed mobility, hygiene, ambulation, and dressing; total dependent for bathing and supervision/set up for eating. Section V - Care Area Assessment Summary (CAA) of the MDS documented the following areas triggered for care plan development/review: 2. Cognitive loss/dementia; 5. ADL Functional/Rehabilitation Potential; 6. Urinary Incontinence and Indwelling Catheter; 7. Psychosocial Well-Being; 8. Mood State; 10. Activities; 11. Falls; 12. Nutritional Status; 16. Pressure Ulcer/Injury; and 17. [CONDITION(S)] Drug Use. On 02/24/2021, Resident #5's clinical record was reviewed. Observed in the progress notes was a note dated 01/21/2021 documenting the IDT (interdisciplinary team) meeting and care plan conference with the responsible party/spouse. The note documented the care plans were reviewed. A review of the clinical record documented a base line care plane dated 01/01/2021. A review of the comprehensive care plans documented 8 pages including the following focus areas: ADL decline - Date Initiated 12/27/2019, Target Date: 01/09/2020; Functional Decline - Date Initiated 12/27/ , Target Dated 01/09/2020; Nutritional - Date Initiated 12/31/ , Target 01/09/2020; Activities - Date Initiated 01/08/2021, Target Date 01/09/2020; Communication (Aphasia) - Date Initiated 12/27/2019, Target Date 01/09/2020; Cognition/Dementia - Date Revised 01/08/2021, Target Date 01/09/2020; Depression - Revision 01/08/2021, Target 01/09/2020; and Adjustment/Isolation - Revision 01/08/2021; Target 01/09/2020. On 02/24/2021 at 10:30 a.m., the MDS Coordinator (RN #1) was asked for the current comprehensive care plans (CCP). RN #1 stated, I will be honest if they are not in the electronic record then they were not done. RN #1 was asked how was care being provided to Resident #5 if there was not a CCP. RN #1 stated, I understand what you are saying. The staff has the baseline care plan and they should be following the physician orders. I am doing the best I can to catch up all of the care plans. On 02/24/2021 at 3:45 p.m. the administrator, DON (director of nursing), and corporate consultant were informed of the above findings during a meeting. The administrator and corporate consultant stated they were aware of an ongoing issue with late care plans and MDS assessments. No other information was received by the survey team prior to exit on 02/25/2021 at 11:45 a.m. 6. Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was the annual/comprehensive assessment and assessed Resident #12 as cognitively intact for daily decision making with a score of 14 out of 15. Under Section G - Functional Status, Resident #12 was assessed as total dependent for transfers, toileting, dressing, bathing, and hygiene; extensive assistance for bed mobility and locomotion; and independent for eating. The MDS assessed Resident #12 has having upper and lower range of motion (ROM) limits on one side. Section V - Care Area Assessment Summary (CAA) of the MDS documented the following areas triggered for care plan development: 4. Communication; 5. ADL Functional/Rehabilitation Potential; 6. Urinary Incontinence and Indwelling Catheter; 11. Falls; 12. Nutritional Status; 15. Dental Care; and, 16. Pressure Ulcer/Injury. A review of the clinical record did not document comprehensive care plans were developed for communication, ADLs, falls, dental care or pressure ulcer/injury. On 02/24/2021, at 10:17 a.m., the MDS Coordinator (RN #1) was asked for the current comprehensive care plans (CCP). RN #1 stated, [Resident #12] has been here awhile and he may have some paper care plans. I haven't had time to enter them all into the electronic medical record yet. They should be on the unit in a pink binder. If you need assistance ask [Medical Records Clerk] and she will help you. On 02/24/2021 at 10:45 a.m., the medical records clerk (OS #1) was asked for assistance in locating the paper care plans for Resident #12. OS #1 checked the pink binder and was not able to locate the paper care plans. OS #1 stated, let me check on the other unit and I will bring them to you if I find them. OS #1 returned at 11:00 a.m. and stated, I'm not able to locate the paper care plans. On 02/24/2021 at 2:45 p.m., RN #1 was advised the paper care plans were not located. RN #1 stated, I will be honest if they are not in the electronic record and the paper care plans weren't located then I'm not sure what may have happened to them. RN #1 was asked if she had developed any new care plans based off the 11/23/2020 annual assessment CAA summary. RN #1, stated I will be honest if they are not in the electronic record then they were not done. I am working on care plans this week and plan to catch them up. On 02/24/2021 at 3:45 p.m. the administrator, DON (director of nursing), and corporate consultant were informed of the above findings during a meeting. The administrator and corporate consultant stated they were aware of an ongoing issue with late care plans and MDS assessments. No other information was received by the survey team prior to exit on 02/25/2021 at 11:45 a.m. 7. Resident #31 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/14/21. Resident #31 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #31 was also assessed as requiring limited assistance of one staff member for transfers, dressing, toileting, hygiene and bathing. On 02/23/21 at 11:18 AM, Resident #31 was interviewed in her room. The resident was in her recliner with her legs elevated. Resident #31 was wearing shorts (legs exposed). The resident's bilateral legs were edematous and red, with open [CONDITION(S)]/blistering and weeping (from the ankles to the knees). The resident's legs also had scaly/flaking skin. The resident's bilateral arms were red with scattered areas of rash and scabs (from the hands upwards to the bicep/shoulder areas). Resident #31 was rubbing and scratching at her arms and stated that it does itch and she has had this condition for a long time. The resident stated that her legs had been like that for a long time also, but she felt it has recently gotten worse over the last few months. Resident #31 stated that she wasn't sure what it was, but had been seeing a dermatologist regularly for about a year and that facility staff were treating it. The resident stated that the facility had ordered her a special wrap for her legs and that was supposed to be in tomorrow (02/34/21). During the conversation, Resident #31 also stated that she had a [CONDITION(S)], staff provide supplies and that she is able to take care of it. The resident also stated that she has had two falls in the last few months, which she had received a moderate skin tears on each arm, one with each fall. During the resident's clinical records review, no CCP (comprehensive care plan) could be located regarding the condition and care of the resident's legs and arms, for [CONDITION(S)] care, or for falls. Nursing notes revealed the resident had a fall on 01/21/21 and sustained a skin tear to the right arm and revealed the resident had a fall on 01/24/21, which resulted in a 'large skin tear to the left arm. On 02/24/21 the resident was observed at 8:00 AM. The resident had bilateral legs wrapped with special dressing per the resident. On 02/24/21 at approximately 2:15 PM, RN (Registered Nurse) #1 was interviewed regarding Resident #31's CCP for the above listed areas and made aware that a CCP could not be found for those areas. RN #1 stated that the resident had a CCP in the computer, but also had one on paper and stated that she would bring a copy of what she had for Resident #31. At approximately 3:30 PM, RN #1 presented the copy of the paper CCP. There was no CCP for the resident's skin condition, the resident's [CONDITION(S)], or for the resident's falls. RN #1 stated that she was the only one doing MDS's and care plans and that she was behind. No further explanation was provided. On 02/24/21 at 4:15 PM, the administrator, DON (director of nursing) and the corporate staff were informed of the above information. No further information and/or documentation was provided prior to the exit conference on 02/25/21 at 11:45 AM. 8. Resident #18 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/01/20. Resident #18 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18 was also assessed as requiring extensive assistance of one staff member for transfers, dressing, toileting, hygiene and bathing. The resident was assessed as requiring limited assistance with one person physical assistance for eating. On 02/23/21 at 12:30 PM, Resident #18 was observed and interviewed. The resident was thin and frail. The resident stated that he has had weight loss. Resident #18 stated that his food is now pureed due to having issues with choking. The resident stated that he doesn't like the pureed food as well as regular and eats what he wants. Resident #18 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/23/21 at 12:50 PM, Resident #18 lunch tray arrived. Resident #18 had mashed potatoes, gravy, pork/gravy, carrots, glucerna, water, diet cola, vanilla cake (all pureed/soft), and the resident's fluids were thickened. The CNA (certified nursing assistant) opened all containers, prepared the tray and the resident began to eat his lunch without difficulty. During clinical record review, it was documented on 12/23/20 that Resident #18 had a chipped tooth. Resident #18 went to a dental appointment on 01/18/21. A future dental appointment was made for the preparation of dental work for dentures. On 02/23/21 at 3:08 PM, Resident #18 was asked about his tooth. The resident stated that he didn't know how it chipped and stated that it did not bother him. The resident stated that he had an upcoming appointment to get his teeth pulled. The resident was asked again about his weight loss at this time. Resident #18 stated that he just can't eat much anymore and eats what he wants. Further review of the resident's clinical record revealed that Resident #18 had a significant weight loss and that appropriate weight loss/nutritional interventions were in place and being implemented. The resident's CCP (comprehensive care plan) was then reviewed. The resident had no CCP for dental or nutrition and/or weight loss. On 02/24/21 at approximately 2:15 PM, RN (Registered Nurse) #1 was interviewed regarding Resident #18's CCP for the above listed areas. RN #1 stated that the resident had a CCP in the computer. RN #1 stated that this resident did not have an additional care plans. RN #1 stated that she was behind on care plans and stated that she was being honest. On 02/24/21 at 4:15 PM, the administrator, DON (director of nursing) and the corporate staff were informed of the above information. No further information and/or documentation was provided prior to the exit conference on 02/25/21 at 11:45 AM. 9. Resident #8 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/4/20. Resident #8 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/23/21 at 11:38 AM Resident #8 was observed laying in bed with dressings to the chest area, back of neck, and a lesion to the left side of face. An interview was attempted but Resident #8 was nonverbal. On 2/24/21 Resident #8's medical record was reviewed. Resident #8's MDS indicated under section M (Skin Conditions) as having skin integrity concerns, and section O (Special Treatments) as being placed on Hospice. Further review of the record documented that Resident #8 had been on hospice since 8/11/20. Resident #8's current care plan was then reviewed and did not evidence a care plan had been developed for skin integrity or hospice. On 02/24/21 at 01:46 PM, registered nurse (RN #1 MDS coordinator) was interviewed concerning care plans not being developed. RN #1 reviewed Resident #8's current care plan and stated that it was an oversight. On 02/24/21 at 1:56 PM, RN #2 (assigned to Resident #8) was interviewed. When asked about Resident #8's skin condition, RN #2 stated Resident #8 had cancer and skin lesion developed on her face, chest and back of neck and as a result Resident #8 had been place on comfort care with hospice. On 02/24/21 at 03:51 PM the above information was presented to the director of nursing and administrator. The administrator stated that he was aware that the MDS coordinator has been backed up in regards to completing care plans. No other information was presented prior to exit conference on 2/25/21. 10. Resident #301 was admitted to the facility on [DATE] with a readmission on 2/17/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 02/5/21. Resident #301 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/23/21 at 11:18 AM, Resident #309 was interviewed. Resident #309 was asked about placement of a catheter. Resident #309 stated that he thought it was placed in June 2020 due to having a stroke and that the catheter was in place before being admitted to the facility. On 2/24/21 Resident #309's medical record was reviewed. Resident #309's admission MDS with an ARD of 11/9/20 section H Bowel and Bladder indicated Resident #309 had an indwelling catheter. Resident #309's current care plan was then reviewed and did not evidence a care plan had been developed for catheter care. On 02/24/21 at 1:46 PM, registered nurse (RN #1 MDS coordinator) was interviewed concerning the catheter care plan. RN #1 reviewed Resident #309's current care plan and stated that it was an oversight and should have been completed. On 02/24/21 at 03:51 PM the above information was presented to the director of nursing and administrator. No other information was presented prior to exit conference on 2/25/21. 11. Resident #11 was originally admitted to the facility on [DATE] and readmitted on [DATE] following hospitalization from [DATE] through 7/3/2020. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 01/27/2021. Resident #11 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Section V- Care Area Assessment (CAA) of the Significant Change MDS with an ARD of 7/14/2020 documented the following care area triggers for Resident #11: [CONDITION(S)], Cognitive Loss/Dementia, Communication, Urinary Incontinence, Psychosocial Well-Being, Falls, Nutritional Status, Pressure Ulcer, and [CONDITION(S)] Drug Use. A review of Resident #11's most recent care plan dated 03/06/2020 lacked an assessment, goal, or intervention for the following triggers: Communication, Urinary Incontinence, Falls, Nutritional Status, and Pressure Ulcer. On 2/24/2021 at 3:00 p.m. the MDS Coordinator/RN (RN #1) was interviewed regarding Resident #11's care plan not being updated. RN #1 stated, Apparently I didn't update her and I should have updated it when I made the changes to the MDS. A review of the facility's policy Goals and Objectives, Care Plans (Revised April 2009) documented: Goals and objectives are reviewed and/or revised: a. When there has been a significant change in the resident's condition, b. When the desired outcome has not been achieved, c. When the resident has been readmitted to the facility from a hospital/rehabilitation stay; and, d. At least quarterly 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. 5. Goals and objectives are reviewed and/or revised: a. when there has been a significant change in the resident's conditions; b. when the desired outcome has not been achieved; c. when the resident has been readmitted to the facility from a hospital/rehabilitation stay, and d. at least quarterly. These findings were reviewed with the Administrator, Director of Nursing, and Director of Operations during a meeting on 2/24/2021 at 4:30 p.m.

Based on clinical record review and staff interview, the facility staff failed to review and revise care plans for two of 22 residents in the survey sample, Resident #12 and Resident #35. Resident #12's care plan had not been reviewed or revised since 04/16/2020. Resident #35's care plan was not reviewed and revised for care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: 1. Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was the annual/comprehensive assessment and assessed Resident #12 as cognitively intact for daily decision making with a score of 14 out of 15. Under Section G - Functional Status, Resident #12 was assessed as total dependent for transfers, toileting, dressing, bathing, and hygiene; extensive assistance for bed mobility and locomotion; and independent for eating. The MDS assessed Resident #12 has having upper and lower range of motion (ROM) limits on one side. On 02/24/2021 Resident #12's clinical record was reviewed. Observed in the progress notes was a note dated 10/08/2020 documented the IDT (interdisciplinary team) meeting and care plan conference. Further review of the clinical record did not include any other IDT and care plan conference notes. Observed in the electronic clinical record were 7 pages of care plans including the following focus areas: pressure ulcer - Revised 10/08/2019, Target Date 12/30/2019; nutrition - Revised 01/15/2020, Target Date 06/15/2020, activities - Revised 03/24/2020 Target Date - 06/19/2020; ADL (occupational therapy) - Revised 04/16/2020, Target Date 12/30/2020; ADL (physical therapy) - Revised 04/16/2020, Target Date 12/30/2020; and psychosocial - Revised 03/23/2020, Target 12/30/2019. A review of the care plans failed to document they were reviewed and revised in a timely manner to reflect the interventions necessary for Resident #12's care. On 02/24/2021 at 10:17 a.m., the MDS coordinator (RN #1) was interviewed regarding the care plan meeting and revision of the care plans. RN #1 stated, I know there has been a care plan conference since September. I may have forgotten to enter a progress note. RN #1 provided a copy of the IDT and care plan conference sheet dated 12/31/2020. RN #1 stated, It has taken me almost two years to get caught up and I still feel like I'm behind with COVID and having to do all of the assessments and care plans it's just a lot of work for one person. We had the care plan conference, but the care plans were not reviewed and revised timely. RN #1 was asked if the care plans were reviewed during the meetings with the IDT, resident and/or responsible party. RN #1 stated, The meetings are scheduled for 15 minutes. I will review the physician orders, behaviors, nutritional and any acute items; however, we just don't have the time to review the full care plan at the meeting. RN #1 was asked when the care plans were reviewed and revised. RN #1 stated, I am working on catching them up now. On 02/24/2021 at 3:45 p.m. the administrator, DON (director of nursing), and corporate consultant were informed of the above findings during a meeting. The administrator and corporate consultant stated they were aware of an ongoing issue with late care plans and MDS assessments. No other information was received by the survey team prior to exit on 02/25/2021 at 11:45 a.m. 2. Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #35 with short and long-term memory problems and severely impaired cognitive skills. This MDS listed the resident required the extensive assistance of two people for bed mobility and had impaired range of motion of her upper and lower extremities. Resident #35's clinical record documented the resident currently had a pressure ulcer on her sacrum. The record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35's most recent pressure ulcer assessment dated [DATE] documented a stage 4 pressure ulcer measuring 7 x 9 x 3 (length by width by depth in centimeters) with serosanguineous drainage and no odor. This assessment documented the pressure ulcer originated as a stage 2 ulcer on 11/16/20. Resident #35's plan of care (revised 2/24/21) was not updated to include problems, goals and/or interventions for the sacral pressure ulcer. The care plan listed the resident had .the potential for pressure ulcer development r/t [due to] impaired mobility, incontinence (bowel/bladder), Braden score of 13 (moderate risk) and hx. [history] of previous skin impairment . The care plan listed the resident had skin impairment on the right groin and pubic area but made no mention the resident had a pressure ulcer on the sacrum. On 2/24/21 at 8:26 a.m., the registered nurse (RN #1) responsible for care plans was interviewed about Resident #35. RN #1 stated she was behind on care plans. Regarding Resident #35's plan, RN #1 stated what was in the electronic health record was the current plan of care. RN #1 did not know why the pressure ulcer had not been added to the care plan. A review of the facility's policy titled Goals and Objectives, Care Plans documented the following: 5 Goals and objectives are reviewed and/or revised: a. when there has been a significant change in the resident's conditions; b. when the desired outcome has not been achieved; c. when the resident has been readmitted to the facility from a hospital/rehabilitation stay, and d. at least quarterly. This finding was reviewed with the administrator and director of nursing during a meeting on 2/24/21 at 4:00 p.m.

Based on observations, staff interview and clinical record review, the facility staff failed to provide assistive devices for one of 22 residents in the survey sample, Resident #44, and failed to ensure a safe bed environment for one of 22 residents, Resident #35. Resident #44, who was identified as having a history of falls was observed without bilateral falls mats to each side of the bed. Resident #35's bed rails/grab bars were observed with a bent clip with a sharp edge. The findings include: 1. Resident #44 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included stroke, [CONDITION(S)], hypertension, [CONDITION(S)], type two diabetes, Non-Alzheimer's disease, and depression. The most recent minimum data set (MDS) dated [DATE] which was a 5-day assessment, assessed Resident #44 as severely impaired for daily decision making with a score of 6 out 15 with periods of fluctuating inattention and disorganized thinking. Under section G - Functional Status, Resident #44 was assessed as total dependent for hygiene, bathing, and toileting and extensive assistance for dressing, transfers, bed mobility, and eating. Under section J - Fall History, Resident #44 was assessed with having a fall since readmission. On 02/23/2021 Resident #44's clinical record was reviewed. Observed in the progress notes was the following nursing note: 02/8/2021 06:43 Observed patient lying face down on floor mat on floor between bed and wall. Patient denied pain. Patient stated, I was reaching for the cat. ROM (range of motion) to all extremities. Full body assessment revealed small abrasion to right patella, which required no treatment. Staff report patient did not hit her head. Total 4 person assist transfer from floor to bed via [NAME] lift. Safety precautions in place. Call bell is within reach. Will continue to monitor. MD (medical director) and [Responsible Party] both notified. Observed on the care plan was the following: Focus: Resident has hx (history) of falls and potential for further falls r/t (related to) impaired mobility, cognitive impairment with poor safety awareness and use of [CONDITION(S)] meds. Goal: The resident will have a decrease in falls and not sustain any further serious injury through the review date. Interventions: Floor mat to both sides of bed Revision on: 02/23/2021 . On 02/24/2021 at 08:15 a.m. and at 08:42 a.m., Resident #44 was observed laying in bed waiting for breakfast. There were no fall mats observed at either time. On 02/24/21 at 08:45 a.m., the certified nursing assistance (CNA #1) who routinely provides care for Resident #44 was interviewed regarding the fall mats. CNA #1 stated, yes she [Resident #44) is supposed to have the fall mats down. I've looked around the room and can't find them anywhere. I think when she was moved from the other room to this room, whoever moved her probably left the fall mats in the other room. On 02/24/2021 at 9:00 a.m., RN #2 who routinely provides care for Resident #44 was interviewed regarding the implementation of fall mats. RN #2 stated, nursing including the CNAs are responsible to make sure the fall mats are in place. On 02/24/2021 at 3:45 p.m. the administrator, DON (director of nursing), and corporate consultant were informed of the above findings during a meeting. No other information was received by the survey team prior to exit on 02/25/2021 at 11:45 a.m. 2. Resident #35 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, [CONDITION(S)] with behavioral disturbance, hypertension, [CONDITION(S)], [CONDITION(S)] and COVID-19. The minimum data set (MDS) dated [DATE] assessed Resident #35 with short and long-term memory problems and severely impaired cognitive skills. This MDS listed the resident required the extensive assistance of two people for bed mobility and had impaired range of motion of her upper and lower extremities. On 2/23/21 at 11:12 a.m., Resident #35 was observed in bed. The resident had a protective geri-sleeve on her left hand/forearm. U-shaped side rails were up on both sides of the bed near the head. The left rail (on side near center of room) had two metal clips holding an attached accessory bag. The left side of the accessory bag was torn from the rail and hanging unattached to the hook. The clip/hook on the left arm of this rail was bent with sharp edges exposed along the edge of the hook. Resident #35 was observed in bed on 2/23/21 at 12:00 p.m. and at 12:40 p.m., with the side rails up and the bent hook/clip exposed on the left rail. On 2/24/21 at 10:13 a.m., accompanied by registered nurse (RN) #4 and certified nurses' aide (CNA) #1, a dressing change on Resident #35's sacrum was observed. During this dressing change, Resident #35 moved her right arm about and grabbed/held onto the left side rail with her right hand. Resident #35's plan of care (revised 2/24/21) listed the resident was at risk of injury due to impaired mobility, cognitive impairment and poor safety awareness and had high potential for skin impairment. The care plan documented, .is physically aggressive (scratching, hitting, grabbing during ADL care) and yells r/t Dementia . Interventions to prevent injury and protect skin included providing safe environment, grab bars to bed to assist resident with positioning/mobility and intervene before agitation escalates. On 2/23/21 at 10:30 a.m., CNA #1 was interviewed about the bent, exposed clip/hook on the arm of the left rail. CNA#1 stated the hook/clip was there to hold the accessory bag in place. CNA #1 stated the accessory bag had been torn loose from the hook on the left side. CNA #1 stated she did not realize the clip/hook was bent outward. CNA #1 stated the resident was able to grab/hold the rail when assisted during care. On 2/23/21 at 10:35 a.m., RN #4 was interviewed about the bent hook on the rail. RN #4 stated she did not realize the hook was bent and/or exposed. RN #4 stated the resident had a strong grip and held the rail when assisted during care. This finding was reviewed with the administrator and director of nursing during a meeting on 2/24/21 at 4:00 p.m.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to obtain informed consent and attempt alternatives prior to the use of bed rails for one of 22 residents in the survey sample. Resident #35, assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data sets (MDS) dated [DATE], 12/5/20 and 1/30/21 assessed Resident #35 with short and long-term memory problems and severely impaired cognitive skills. On 2/23/21 at 11:12 a.m., Resident #35 was observed in bed with U-shaped side rails up on both sides of the bed near the head. The resident was observed in bed on 2/23/21 at 12:00 p.m. and at 12:40 p.m. with the side rails in the up position. Resident #35's clinical record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's plan of care (revised 2/24/21) listed grab rails were used for positioning/mobility when providing activities of daily living. The clinical record documented an Evaluation for Use of Bed Rails form dated 10/26/20. This form documented Resident #35 requested use of the side rails for movement when in bed and listed the resident had dementia and increased agitation at times. The form documented that partial (1/4 length) bed rails were recommended due to resident request. The form listed no attempted alternatives to the rails and no risks/benefits associated with bed rail use. The form documented bed rail precautions and alternatives to bed rails had been discussed with the resident. There was no documentation in the clinical record indicating the resident's family/representative had been informed about the risks/benefits of bed rail use prior to their use. There were no documented attempted alternatives to the bed rails. On 2/24/21 at 1:50 p.m., the registered nurse (RN #2) that completed the bed rail evaluation dated 10/26/20 was interviewed. RN #2 stated Resident #35 was able to hold/grab the side rails when turned in bed during personal care. RN #2 stated the bed rails for Resident #35 were discussed in their daily stand-up meeting but she did not discuss them with the resident's family or representative. When asked if the resident, assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 stated the risks/benefits should have been discussed with the family prior to use because the resident was not able to understand safety concerns due to severe cognitive impairment. RN#2 was not aware of any attempted alternatives prior to use of bed rails with Resident #35. The facility's policy titled Bed Safety (revised December 2007) documented, The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment .Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails . This finding was reviewed with the administrator and director of nursing during a meeting on 2/24/21 at 4:00 p.m.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not readily available for distribution on the East Wing. The findings include: On 02/23/2021 at 12:23 p.m. medication storage observations were conducted on the East Wing with RN #2 (registered nurse). An opened bottle of GERICARE 24 Hour Non-drowsy [MEDICATION(S)] [MEDICATION(S)] 10 mg (milligrams) tablets was observed with an expiration date of 01/2021 on the 200-300 East Wing medication cart. Additionally, an unopened bottle of the same medication with an expiration date of 08/2020 was observed in the medication storage room on the East Wing. RN #2 observed both bottles of expired medications. On 02/23/2021 at 12:45 p.m., RN #2 was interviewed regarding expired medication. RN #2 stated nursing should check the medication cart and storage room at least once or twice weekly to ensure medications are in date and any expired medications are destroyed. A review of the facility's medication storage policy documented the following: .5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed On 02/24/2021 at 3:45 p.m. the administrator, DON (director of nursing), and corporate consultant were informed of the above findings during a meeting. No other information was provided to the survey team prior to the exit conference on 02/25/2021 at 11:45 a.m.

Based on observation, staff interview, and facility document review, it was determined that the facility failed to store and label food in a sanitary manner and failed to follow proper sanitizing procedures. The findings include: On [DATE] at 10:35 a.m. while accompanied by kitchen staff (other staff #3), food items in the walk-in freezer were inspected and an unlabeled, undated, frozen container was found. When asked, OS #3 reported that it was sausage gravy. Food items in the walk-in refrigerator were inspected and a container of peas was found with no label or date. OS #3 was interviewed at the time of the observations and stated the containers should have been labeled and did not know why they were not. On [DATE] at 10:45 a.m., OS #3 was observed conducting a test of the 3-compartment sink using a test strip. OS #3 stated the results were 100 ppm (parts per million). When asked what the results are supposed to be, OS #3 stated she did not know and that she usually just recorded the results on the test log. An inspection of the test strip container revealed an expiration date of [DATE]. When asked where new test strips were kept, OS #3 stated the strips were locked up and only the dietary manager had access to them. On [DATE] at 2:40 p.m. the dietary manager (other staff #4) was interviewed about the unlabeled food containers and expired test strips. OS #4 stated the test strips were kept in a drawer that staff should have access to. OS #4 also stated that the food containers should be labeled and dated but that sometimes the labels do not stick to the containers that well. A review of the facility's policy titled Food Receiving and Storage (revised [DATE]) documented, dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). The policy also documented, all foods stored in the refrigerated or freezer will be covered, labeled and dated (use by date). A review of the facility's policy titled Pots and Pans- Sanitizing Solution (revised [DATE]) documented regarding the test of sanitizer concentration, 200 ppm .is the required concentration of sanitizer-to-water ratio using a quaternary [MEDICATION(S)]-based sanitizer. These findings were reviewed with the Administrator, Director of Nursing, and Director of Operations during a meeting on [DATE] at 4:30 p.m.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate medical record for one of 22 residents in the survey sample, Resident #47B. No documentation was entered in Resident #47B's record regarding her death on [DATE]. Findings were: Resident #47B was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Alzheimer's, dementia, [CONDITION(S)], seizures, and [CONDITION(S)]. A quarterly MDS (minimum data set) completed [DATE], assessed Resident #47B as severely impaired with a cognitive summary score of 00. The clinical record was reviewed on [DATE] at approximately 11:30 a.m. Resident #47B was discharged from the facility on [DATE]. A discharge MDS with an ARD (assessment reference date) of [DATE] coded Resident #47B's reason for discharge as Death in Facility. The progress note section was reviewed. The following entries for Resident #47B were observed: [DATE] 15:25 [3:25 p.m.] O2 SATS [oxygen saturation] WARNING: Value: 85.0 .MD made aware. Order for hospice referral received; RP [responsible party] aware and is in agreeance [sic]. [DATE] 15:27 [3:27 p.m.] Resident ate less than 50% of meal; resident is transitioning and not currently taking P.O. [by mouth]. There were no further progress notes for Resident #47B. A transfer/discharge summary was observed in the record that contained Resident #47B's demographic information, diagnoses, and the date and time of transfer to a local funeral home. The DON (director of nursing) was interviewed on [DATE] at approximately 12:50 p.m. regarding Resident #47B. She was asked if there was any other documentation regarding Resident #47B's death. She stated she would look and see what she could find. At 1:30 p.m. and additional note was observed in the progress note section of the chart which read: [DATE] 13:12 [1:12 p.m.] Late entry for [DATE]. Resident in bed, daughter @ bedside. Resident without pulse or respirations. RN in to pronounce. The DON was interviewed at 1:50 p.m. regarding the addendum to the clinical record. She stated, Yes, I had [name of nurse] do a late entry. She was here at the time. The nurse who was working that night with [name of Resident #47B] is no longer working here. The DON was asked what time Resident #47B had died and if additional documentation should have been done at the time of death. She stated, She died at 3:10 a.m .There should be more information documented .We are also scanning in her hospice notes, they did come in before she died .the nurse should have documented more in the record. The DON was asked if hospice was onsite at the time of Resident #47B's death. She stated, No. No further information was obtained prior to the exit conference on [DATE].

Based on observation, staff interview and facility document review, the facility staff failed to follow infection control practices during a dining observation on one of two nursing units. A staff member failed to perform hand hygiene between residents during a meal observation on the West unit. The findings include: On 2/23/21 at 12:43 p.m., a dining observation was conducted on the West unit. Without prior hand hygiene, certified nurses' aide (CNA) #1 was observed assisting Resident #36 out of bed and into a chair. CNA #1 touched the resident's bed covers, the resident's arm, and chair during the transfer. CNA #1 proceeded to set-up the resident's meal tray using the resident's utensils. Without performing hand hygiene, CNA #1 went to the rack and touched several items on three meal trays looking for meal tickets. Without prior hand hygiene, CNA #1 served a lunch tray to Resident #20. CNA #1 used the resident's utensils to cut food items, butter bread and provide tray set-up. On 2/23/21 at 12:55 p.m., CNA #1 was interviewed about hand hygiene between residents during meal service. CNA #1 stated, I know I missed a couple of times. CNA #1 stated she usually carried a container of hand sanitizer in her pocket but did not have it with her today. CNA #1 stated, I don't have mine [sanitizer] on me. CNA #1 stated she was supposed to use sanitizer or wash hands after contact with each resident. When asked if she had access to more sanitizer, CNA #1 stated there was a bottle of sanitizer on the medication cart. On 2/24/21 at 8:38 a.m., the registered nurse infection preventionist (RN #5) was interviewed about protocols for hand hygiene. RN #5 stated staff members were supposed to wash hands or use sanitizer before and after contact with residents and their personal items. The facility's policy titled Handwashing/Hand Hygiene (revised August 2019) documented, This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors .Use an alcohol-based hand rub .or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following .Before and after direct contact with residents .After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident .Before and after assisting a resident with meals . This finding was reviewed with the administrator and director of nursing during a meeting on 2/24/21 at 4:00 p.m.

Based on staff interview and clinical record review, the facility failed to develop a baseline care plan for skin integrity for for one of 37 Residents, Resident #198. The findings Include: Resident #198 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was an entry assessment with an ARD (assessment reference date) of 02/15/21. Resident #198 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/24/21 Resident #198's medical record was reviewed and indicated that Resident #198 was newly admitted with a stage 2 pressure ulcer to right buttock. Review of Resident #198's baseline care plan dated 2/15/21 documented a check mark beside current skin integrity issues and indicating a stage 2 pressure ulcer on the right buttock, but did not indicate any goals or interventions for the care of Resident #198's pressure ulcer. On 02/24/21 at 01:46 PM, registered nurse (RN #1 MDS coordinator) was interviewed. RN #1 stated that the nurses on the floor are responsible to complete a baseline care plan upon admission. RN #1 then reviewed the care plan and stated that the baseline care plan tool does not have a place to document interventions. On 02/24/21 at 01:56 PM, RN #2 (assigned to Resident #198) was interviewed regarding baseline care plans. RN #2 stated there is no place to put interventions on the baseline care plan and thought it was sent over to MDS coordinator to complete. On 02/24/21 at 03:51 PM, the survey team met with the administrator and director of nursing (DON) and was presented with the above finding. No there information was presented prior to exit on 02/25/21.

Based on complaint investigation, clinical record review, staff interview, and facility document review, the facility failed to ensure that two of four residents in the survey sample (Residents # 2 and 3) were free of accidents that resulted in harm; AND, failed to ensure that four of seven interviewed facility staff were knowledgeable about the facility's door alarm system. Residents # 2 and 3 suffered falls which resulted in fractures. Four of seven staff members were unable to explain or correctly identify the correlation between exit doors and the corresponding lights on each of the facility's two door alarm panels. The findings include: 1. Resident # 2 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included [CONDITION(S)], Non-Alzheimer's dementia, anxiety disorder, depression, [CONDITION(S)], contractures of the left and right feet, and fracture of the left humerus. According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 10/10/19, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 08 out of 15. Under Section G (Functional Status), the resident was assessed as totally dependent with two persons physical assist for transfer; as totally dependent with one person physical assist for locomotion on and off the nursing unit, hygiene, and bathing; as needing extensive assistance with one person physical assist for bed mobility and dressing; and as independent with set-up help only for eating. Review of Resident # 2's hard copy clinical record revealed the following Nurses Notes: 7/19/19 - 8:30 p.m. Resident was in bed, rolled out of bed on to floor face forward. Resident head on floor. Nose bleeding. Resident c/o (complained of) excruciating pain in left arm. Resident requested to go to hospital for medical care. 911 called. 7/20/19 - 3:00 a.m. Resident returned to facility via transport. Alert & verbal. Diagnosis from hospital is L (Left) humerus fracture, skin tear of upper extremity. Humerus has been placed in sling and skin tear was dressed at the hospital 7/20/19 - 7:00 a.m. CNA (Certified Nursing Assistant) stated that wheels on bed were broken and bed was not locked when she was changing resident. She went to get wipes and the bed rolled and the resident fell out of bed. A witness statement from the LPN (Licensed Practical Nurse) on duty at the time noted the following, CNA called me to room where resident was laying face down on the floor. CNA stated that resident rolled out of bed while she was changing her. Resident head (with) lump above right eye and complained of severe pain. EMS called to pick resident up for evaluation. A witness statement from CNA # 4, who was attending to Resident # 2, noted the following, I was changing resident, from one side to the other, as I was getting wipes the bed moved and the resident rolled on to the floor, I set (sic) with her until rescue came. At 3:30 p.m. on 11/12/19, CNA # 4 was interviewed and was asked to explain what happened on the night the resident fell . CNA # 4 said the resident needs two persons to transfer, but only one when changing briefs. She went on to say that she had rolled the resident over and was reaching for some wipes when the resident reached out and pushed on the nightstand next to her bed. I think she was trying to help me, but when she pushed on the nightstand, the bed moved and she rolled out of it, CNA # 4 said. Asked how often she provided care for Resident # 2, she said that night was the first time she had cared for her. At 12 noon on 11/12/19, the Maintenance Director was interviewed regarding the brakes on resident beds. If the brakes are broken on these old beds, the Maintenance Director said, I just put a screw in the [NAME] (wheel) to keep it from turning. Asked how he documents requests to repair the brakes on resident beds, and if the broken brakes on Resident # 2's bed were reported to him, the Maintenance Director said, I keep a log and a journal. Some times it's just a verbal request. At 12:10 p.m. on 11/12/19, the Maintenance Director returned with his log book and journal. According to the log book, the brakes on Resident # 2's bed were reported as broken on 7/14/19, and according to the journal, the brakes were repaired on 7/15/19. The Maintenance Director indicated he repaired the brakes by putting a screw in the [NAME]. Review of the facility's Incident/Accident Report, dated 7/19/19, noted the following under the item Steps Taken to Prevent Recurrence: Need locks on wheels of bed. Educate staff with two person assist. At approximately 10:30 a.m. on 11/13/19, observation of Resident # 2's bed found it to be on four legs without casters in place. When the Director of Nursing (DON) was asked if she knew when the resident received a new bed, she said she did not know but would check with maintenance. At approximately 10:50 a.m. on 11/13/19, the DON reported back that according to the Maintenance Director, Resident # 2's bed was replaced on 7/19/19. During a meeting at 11:40 a.m. on 11/13/19, the survey team discussed the findings with the Administrator, Director of Nursing, Assistant Director of Nursing, and one of the Unit Managers. 2. Resident # 3 was admitted to the facility 02/01/2016 with the following diagnoses, including but not limited to: [CONDITION(S)] disorder, dementia, and anxiety. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 08/02/2019. Resident #3 was assessed as severely impaired with a cognitive summary score of 03. On 11/12/2019 at approximately 11:30 a.m. Resident #3 was observed lying on her bed. She was asked if she had a recent fall. She stated, Yes, can you get me some pop? She was asked how she had fallen. She stated, I was outside, can I have some pop? Resident #3 was asked if she was with someone when she fell . She stated, No .can I have some pop? The clinical record was reviewed beginning at approximately 11:40 a.m. Discharge instructions from a local emergency department dated 11/18/2019 were observed and contained the following: Diagnosis: 1. Greater Trochanter fracture; 2: Fall; 3. Dementia .you were diagnosed today with a fall and fracture of the greater trochanter of your right hip. This is not a typical fracture and you need to use a walker when walking and you can bear weight as tolerated. You need to follow-up with the orthopedic team in 10 days to 2 weeks . The most recent fall risk evaluation was dated 05/03/2019 and assessed Resident #3 as a HIGH RISK for potential falls with a score of 17. A Wandering and Elopement Risk assessment dated [DATE] contained the following statement, No wandering or exit seeking behavior. The following documentation was observed in the progress notes: 10/19/2019 01:22 [1:22 a.m.] Returned to facility from [hospital name] via stretcher .diagnosed with fall and fracture of greater trochanter of the right hip. WBAT [weight bearing as tolerated] moans in pain with movement . 10/23/2019 14:59 [2:59 p.m.] Late entry for 10/17/2019 Time: 1630 [4:30 p.m.] Was alerted down hallway by other staff member. Upon going down hallway to outside door, pt [patient] was observed lying on left side, Pt was awake, talking. Pt was checked before moving her. Was brought in building in w/c [wheelchair]. Was stating that her leg was hurting, Pt was saying she wanted to go outside. Notified MD and order received to sent pt to ER for eval due to complaint of pain. The care plan documented the following: 2/22/2018 Resident with potential for falls due to decreased safety awareness and use of [CONDITION(S)] medications . Interventions included but were not limited to: Fall risk assessment updated quarterly, annually, and with any change in condition; Redirect her to her room as needed . Additionally, 02/22/2018 Resident with hx [history] of inappropriate behaviors . Interventions included but were not limited to: Maintain door alarms per facility protocol . Problem: 02/22/2018 Resident wanders into other resident rooms .Inteventions: Keep room darkened as much as possible, assist resident back into bed, provide snacks redirection our of other resident rooms . At approximately 2:00 p.m. the door where Resident #3 exited the building was observed. The door was located at the end of the hallway. RN [registered nurse] #1 was in the hallway and was asked if the door had an alarm if opened. She stated, Yes. She was asked if she knew anything about Resident #3's fall outside. She stated, I wasn't over here when it happened It's my understanding that the alarm on the door was working. A staff member at the nurse's station was alerted by RN #1 that the door was going to be opened. She then stated, Go ahead and open it [name] will reset it at the nurse's station. The door was pushed open and a low toned alarm was heard. An investigation regarding the accident was requested and received from the DON (director of nursing). The incident form documented: .Resident was found outside of building. Door alarm had sounded before pt was found outside Predisposing Situation Factors Ambulating without assist . LPN (licensed practical nurse) #1 had completed the incident report and had written the late entry regarding the fall. She was interviewed on 11/12/2019 at approximately 3:00 p.m. She was asked what had happened. She stated, I had just come in and the alarm went off .we checked the doors and we didn't see anyone .I turned off the alarm and reset it .about 5 -10 minutes later [name of RN #1] came over to that side .we talked for a few minutes and then she walked down the hallway to leave. We heard her say, 'Oh my God' .the resident was laying outside .we ran down there and got her up and back inside with a wheelchair .she ended up going to the hospital and her hip was broken. LPN #1 was asked what she meant when she said reset the alarm. She stated, There's a control panel at the nurse's station, when the alarm sounds we don't really know which door it is, we just have to run around and check them. She was asked if she or any of the other staff had walked all the way down the hallways and looked out the doors. She stated, I didn't walk all the way to the doors, I don't know about anybody else. She was asked why they thought the alarm had gone off if they didn't see anyone outside. She stated, I don't know. She was asked how Resident #3 had gotten down the hall and out the door without anyone seeing her. She stated, I don't know. RN #1 was interviewed on 11/12/2019 at approximately 4:45 p.m. about Resident #3's fall. She stated, I was working on the other side [east wing] that day, but I am the unit manager on the west side. I always go over there and check on things before I leave for the day. When I got over there they told me that the alarm had gone off and they didn't know why. We talked about the weekend and then I started down the hall to leave .I was there maybe 5-10 minutes. I always walk down that hallway, turn to the left and then go out the door in the back. When I got down there I looked out the door, that's just my habit, and I saw [name of Resident #3] laying there out of my peripheral vision. I thought I'm not seeing this. I yelled for help and we got her up and brought her back inside in a wheelchair. She was sent out and came back with a broken hip. RN #1 was asked why they staff had not seen her when the alarm went off. She stated, I don't know .I got a quick course from [name of staff] on how the alarms work and what number on the panel goes with what door, but I don't think all the doors are marked with numbers. The above information was discussed during an end of the day meeting on 11/12/2019 with the DON and the administrator. The administrator stated, I don't know why they don't know what number goes with what door, they disarm them when the funeral home comes to pick up a body. The DON was asked how the staff was educated on the alarm panels. She stated, It is part of the facility tour. They should know that. The DON was asked how often the facility assessments regarding falls and wandering were completed. She stated, They should be done quarterly. She was asked if she was aware that Resident #3's last assessments were done in May. She stated, No, I wasn't. 3. On 11/13/2019 the maintenance director was at the nurse's station on the west wing. He was asked about the control panel for door alarms. He stated, The doors are labeled and the number of the door is the number that lights up on the panel. He was asked if he trained new staff members on that. He stated, No, my job is to test them every Wednesday. The door at the end of the hallway where Resident #3 exited was observed; the maintenance director stated, That's door number 7. There was not a number on the door identifying what it's number was. The maintenance director stated, We had those windows tinted, it may have come off then. He pointed down the 500 hallway and stated, That's door number 8, the 400 hall is number 7 and the 600 hall is number 9. The 500 hallway door was observed and was labeled with the number 9. He stated, Part of the tape may have come off I'll fix it. All exit doors in the facility were then inspected with the maintenance director. There was not a number on the door for the 200 hallway on the east wing. He stated, It's suppose to be number 3. The maintenance director was asked how staff would know what door to go to if the alarm went off and the number on the panel didn't coincide with the door. He stated, They should know what they are .it would make sense to me that the doors were numbered the same as the hallway, but that's not how it is. A total of seven staff members (including LPN #1 who was interviewed on 11/12/2019) were interviewed regarding the door alarms. Four of the seven staff members did not know how the alarms coincided with the facility doors. CNA (Certified nursing assistant) #2 stated, I don't know anything about that .I just know when the alarms sounds, one of the doors has been opened and I run around like crazy until we figure out what happened. CNA #3 stated, I don't know the door numbers. When the alarm rings I just go and look. RN #3 stated, Don't quote me but I think that door down there (pointing to the 400 hall door) is 7 .no wait, it might be 8 .I'm not sure .I just know that if the alarm sounds and I don't know then I can go to the diagram next to the control panel and look at that. RN #3 went to the nurse's station and looked at the diagram that was divided into Zones. She stated, Wait a minute, I am wrong .they don't coincide .I don't know. RN #1 was interviewed on 11/13/2019 at approximately 9:00 a.m., regarding the location of Resident #3 when she was found outside. She walked down the hallway and pointed, She was at the end of that railing. RN #3 was asked if she thought Resident #3 could have been seen without staff coming all the way down the hallway to the door. She walked back up the hallway and turned around looking out the door and stated, No, they would have had to walk all the way down to see her. No further information was obtained prior to the exit conference on 11/13/2019.

Based on observation, staff interview, clinical record review and in the course of a complaint investigation, facility staff failed to provide supervision to prevent injuries for two of 18 residents (Residents #4 and #11), resulting in harm for one resident (Residents #4) and failed to properly assess residents for use of siderails for four of 18 residents in the survey sample, Residents #5, #8, #12 and #6. 1. Resident #4 was left unattended in the restorative dining room on 11/20/16 resulting in a fall from her wheelchair (w/c) resulting in harm to this resident. Resident #4 required sutures to a 12 cm (centimeter) laceration to the left side of her forehead resulting in harm. 2. Resident #11 was left unattended on two different occasions both resulting in falls with injuries. Resident #11 was left unattended during an activity on 12/23/2016 and while reaching for a bag of candy on the floor she fell from her chair and hit her head. Resident #11 was again left unattended in her room on 02/16/2017 and while reaching down to pick up her makeup brush from the floor, she fell out of the wheelchair and hit her head. Both falls resulted in emergency room visits. 3. Resident #5, with severe cognitive impairment and multiple falls from his bed, had bed side rails in use without an accurate assessment for safe use of the rails. 4. Resident #8, with severe cognitive impairment and poor safety awareness, had bed side rails in use without an accurate assessment for safe use of the rails. 5. Resident #12 did not have a chair alarm in use for fall prevention as required in her plan of care and had bed side rails in use without a completed assessment for safe use of the rails. 6. Resident #6 had an inaccurate and incomplete assessment for the use of bed siderails. Findings included: 1. Resident #4 was left unattended in the restorative dining room on 11/20/16 resulting in a fall from her wheelchair (w/c) resulting in harm to this resident. Resident #4 required sutures to a 12 cm (centimeter) laceration to the left side of her forehead resulting in harm. Resident #4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 02/03/2017. Resident #4 was assessed as severely impaired in her cognitive skills with a total cognitive score of three out of 15. During the review of Resident #4's clinical record on 02/28/17 at 9:45 a.m. a Nurse's Note dated 11/20/16 1745 (5:45 p.m.) included, Resident observed in dining room on floor by CNA (certified nursing assistant). Resident on (L) (left) side with face to floor . 1810 (6:10 p.m.) To ER (emergency room ) . A SBAR Communication Form dated 11/20/16 stated, .resident fell , lacerated forehead . The Administrator and DON (director of nursing) were asked for an accident report or investigation on 02/28/17 at approximately 3:00 p.m. This surveyor received a copy of an incident/accident report dated 11-20-16 1745 (5:45 p.m.). Location of accident: Feeders dining room. Describe what happened: Resident sitting in w/c in dining room, leaned forward and fell out of chair. Injuries: Laceration to forehead. Witness statement dated 11-21-16 at 2:46 p.m. signed by a CNA included the following: I asked one of the CNA's who was going to the dining room, was not written on schedule aide said she would pass hall trays. I went to the dining room thought someone was in the feeding room, otherwise we are not to leave patients in room. While passing trays went down hall to drop a tray off immediately dropped the tray on nurse's station heard a patient yell help someone is on the floor. Found pt (patient) on floor face down laceration on head puddle of blood on floor wheelchair side parralell (sic) to table. (sic) A second witness statement dated 11/20/16 at 2nd shift (Dinner time) signed by a CNA included the following: Resident was on the dinning (sic) room floor as I walked by the feeder assisting dinning (sic) room door. A resident shouted 'help someone is on the floor.' Resident was bleeding from their head. A third witness statement, not dated or timed, signed by a CNA included, I observe (Name) Resident #4 laying on the floor with the wheelchair turned to the left and was laying on the floor. When everyone started walking and sayed (sic) resident was on floor. I stop passing trays and ran to the seen. (sic) Previously resident has been noticed leaning toward right side a lot. Staff has straigthen (sic) her multiply (sic) times. The ER (emergency room ) visit report included, .Date: 11/20/2016 .Physician Assessment: A 12 cm complex laceration of the brow. Plan: Repair here with sutures .Nursing Assessment Note: 18:30 (6:30 p.m.) Pt. presents to the ED after a fall occurred at the (facility name) where she is living. The fall was witnessed by a resident and related back to the nurse. The pt. was in the dining hall and they say that she fell forward out of her wheelchair and face first onto the ground. They deny any LOC (loss of consciousness). When I called and spoke to her nurse and asked who was supposed to be watching here (sic) and if she was left in the dining hall alone he stated, 'someone was supposed to be watching her but they were not and only the resident saw her fall.' .She has a good sized laceration in the middle of her forehead still actively bleeding .Her left eye is black and blue around the outside .She is currently in a C-collar .She has three quarter sized skin tears on her right upper arm . Several CNA's were interviewed on 02/28/2017 regarding residents in the restorative dining room. At 2:45 p.m., CNA #2 stated, They are to never be left alone. At 2:56 p.m., CNA #3 stated, No ma'am, they are never to be left alone. If you are in the big dining room you take them to the big dining room with you. Do not leave them alone. At 3:50 p.m., CNA #4 stated, I was assigned to her hallway that day. I got her up for dinner and took her to the feeder dining room. The man at the end of her hall wanted a peanut butter and jelly sandwich and we were passing out trays. When I went to get the sandwich I saw her lying in the floor. No one was in there (meaning employees in the restorative dining room) when I found her. Someone is supposed to be in there all the time, actually I think two people. LPN #4 was interviewed via phone at 4:02 p.m. LPN #4 stated, I believe she fell in the dining room. She was leaning forward in her chair. I wasn't present when she fell . They came and got me right quick. She had a pretty bad skin tear. That's really all I remember. The DON (director of nursing) was interviewed on 03/01/17 at 10:25 a.m. regarding when residents are present in the restorative dining room. The DON stated, Yes, someone should be in the restorative dining room if residents are in there. It is staffed for safety in case of choking or falls. I don't know if there is a specific policy for this. It is just how we have always done it. The DON and Administrator were informed of possible harm during this interview. No further information was received by the survey team prior to the exit on 03/01/2017. This is a complaint deficiency. 2. Resident #11 was left unattended on two different occasions both resulting in falls with injuries. Resident #11 was left unattended during an activity on 12/23/2016 and while reaching for a bag of candy on the floor she fell from her chair and hit her head. Resident #11 was again left unattended in her room on 02/16/2017 and while reaching down to pick up her makeup brush from the floor, she fell out of the wheelchair and hit her head. Both falls resulted in emergency room visits. Resident #11 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/30/2016. Resident #11 was assessed as having a cognitive summary score of 08; indicating moderate impairment with her cognitive status. On 02/28/2017, Resident #11 was observed sitting at the end of the hallway at the nurse's station. A golf ball size area was noted on her left forehead. The area was a fading bluish purple in color and was open on the very front of the swelling. A CNA (certified nursing assistant) in the hallway was asked about the area. She stated, That was from a fall. Prior to entering Phase 2 of the survey process a list of all falls for the last three months was requested and received. Resident #11 was on the list for three falls. The first on 12/09/2016 with the explanation that Resident #11 had attempted to transfer herself after her ADL (activities of daily living) care and had fallen. The response to that fall was listed as, Transport to area of visibility when up in wheelchair. The second was on 12/23/2016. Resident #11 was reaching for a bag of candy on the floor and fell from her chair. The response was to educate activity staff to keep resident visible during activities. The third fall was on 02/16/2017. Resident #11 was in her room alone and was reaching for a makeup brush when she fell from her wheelchair. The response to that fall was to repair wheelchair brakes, apply dycem to her wheelchair cushion and do a trial with a reacher. The clinical record and facility investigations were reviewed. The following information was gleaned: 12/09/2016 This nurse was called to room .by another nurse. Resident was lying on floor in front of her w/c (wheelchair) on her back. Resident stated nothing was hurting her ROM (range of motion) to extremities per usual . A review of the facility fall investigation stated that the facility staff would move the resident to areas of visibility when up in her wheelchair to prevent further falls. 12/23/2016 Pt (patient) up in w/c in TV room on East Wing with other residents at activity. States she leaned forward in w/c to pick candy bag off of floor and she fell forward out of w/c - causing hematoma on L (left) forehead. Was lying in floor in front of w/c. Chkd (checked) over and assisted to w/c, then to bed. Pt continues to be awake and verbal .order received to send pt to ER to be evaluated d/t (due to) hematoma to head . A review of the facility incident report was conducted. Steps to prevent reoccurrence for falls were listed as: Have pt visible where staff can see her as much as possible. The care plan was reviewed. The following intervention was added regarding falls on 01/19/2017: DO NOT LEAVE RESIDENT ALONE IN ROOM DUE TO FALL; STAFF EDUCATE (SIC) NOT TO LEAVE IN ROOM ALONE. FREQUENT CHECKS TO ENSURE RESIDENT IS NOT IN ROOM ALONE. 02/16/2017 Resident observed on floor in front of w/c laying on right side, alert and oriented to name, day and place .visible skin tear bilaterally to arms with minimal bleeding. Large raised area to left lateral forehead .sent to emergency department to rule out any type of injury . The facility investigation was reviewed. Steps to prevent reoccurrence included adding dycem to the wheelchair seat, having maintenance check the wheelchair brakes and doing a trial with Resident #11 using a gripper to pick things up from the floor. emergency room notes were reviewed for the fall on 12/23/2016 and 02/16/2017. Resident #11 did not require any sutures to her head and her CT scans were negative during both visits. On 03/01/2017 at approximately 9:15 a.m., this surveyor went to the west wing to interview staff regarding Resident #11's fall on 02/16/2017. The LPN (licensed practical nurse) in charge stated that the CNA (certified nursing assistant) who had gotten Resident #11 up that morning was Off on her honeymoon. She stated, I don't know why she left her but no one was in there when she fell out of the wheelchair. The DON (director of nursing) was interviewed on 03/01/2017 regarding the entries on the care plan and the time line regarding the falls. She stated that the fall interventions dated 1/19/2017 were in place at the time of the fall on 02/16/2017 and should have been in place at the time of the fall on 12/23/2016. On 03/01/2017 at approximately 11:10 a.m. the activity director was interviewed regarding the fall on 12/23/2016 during activities. She stated that she had not done activities that day, her assistant had conducted them while she did paperwork. The assistant was interviewed. She stated that she didn't recall the fall so she must not have witnessed it. She was asked if Residents were normally left alone during activities. She stated, Not usually. The fall as described in the nurse's notes and the facility investigation were recanted with the activities assistant. I must have been in the bathroom. The activities director came to the area where the activities assistant was being interviewed. She stated,I just remembered .we were gathering the residents up for the activities at that time. The assistant stated, That's right .we were .I wasn't in the bathroom .when we are getting the residents in there we don't always have someone in the room. The assistant was told that according to the facility investigation the fall had occurred at 11:50 a.m. She stated, Okay that's it, we were transporting them to lunch after the activity then .there isn't someone in there all the time when we are doing that. The activity assistant was asked if she was aware that Resident #11 was care planned to not be left alone due to her fall history. She stated, No, I didn't know that .she isn't usually in there for activities. The maintenance director was interviewed on 03/01/2017 at approximately 11:20 a.m. regarding the brakes for Resident #11's wheelchair. He stated that he had checked them at the time he got the work order and there was nothing wrong with them. The DON and the administrator were notified of the above information during a meeting on 03/01/2017 at approximately 2:10 p.m. No further information was received prior to the exit conference on 03/01/2017. 3. Resident #5, with severe cognitive impairment and multiple falls from his bed, had bed side rails in use without an accurate assessment for safe use of the rails. Resident #5 was admitted to the facility 11/2/16 with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #5 with severely impaired cognitive skills. This MDS assessed Resident #5 as requiring the extensive assistance of one person for bed mobility, transfers and toileting. On 2/28/17 at 7:45 a.m. Resident #5 was observed in bed with side rails raised on both sides of his bed. The rails was approximately 1/2 length of the bedside. The rails covered the section of the bedside from approximately 12 inches from the head of the bed to the center of the bedside. A pressure activated alarm was in place on the bed. Resident #5 was observed again on 2/28/17 at 1:40 p.m. in bed with side rails raised on both sides of the bed and a bed alarm in place. Resident #5's clinical record documented the resident had bilateral side rails in use on his bed since his admission to the facility on [DATE]. A side rail assessment screening form dated 11/2/16 documented the resident had impaired safety awareness, a history of falls and marked the resident as a low risk for entrapment with a recommendation for 1/2 length bed rails to assist (with) turning/repositioning. The record documented the resident had no falls in the facility until 12/8/16 when the resident slid out of his wheelchair. The resident had five additional falls with all of these five falls from the bed. The facility's fall/incident investigation forms documented the following falls from the resident's bed. 12/16/16 - Found in room on floor sitting in the Doorway had stripped of (off) his shirt + had apparently climbed out of Bed; Bed alarm was in use but alarm was not loud enough to be heard from desk. This report listed the resident was confused, had a history of [REDACTED]. 1/18/17 - Nurse alerted by CNA (certified nurses' aide) at 10:50 p.m. resident was sitting on the floor. Resident observed at foot of bed on left side .with his back against left side foot of bed between wall and bed. Stated he was 'going up there' when asked what happened .foot board applied to bed. This report documented, Resident unaware of when his safety is at risk .Multiple attempts to ambulate from w/c (wheelchair) during the day. Fidgets constantly unable to make needs or wants known .Resident unable to determine what he wants or needs but will exhibit unsafe behaviors when he may be needing something . There was no re-assessment of Resident #5's side rail use following his falls from the bed on 12/6/16 and 1/18/17 until 1/21/17. This side rail assessment form was incomplete and inaccurate. The assessment criteria section of the 1/21/17 form listed the resident had altered safety awareness, a history of falls, poor bed mobility, was on medications requiring increased safety precautions and had a history of [REDACTED]. The section for factors indicating a high risk for injury/entrapment inaccurately listed the resident as able to safely transfer from bed to wheelchair, as able to ambulate to and from the toilet without falling, as consistent with notifying staff of needs and as able to use his call bell. The form listed side rails were indicated to provide safety but listed no medical conditions addressed by use of the rails. This form listed the rails were indicated to serve as an enabler to promote independence and to prevent the resident from voluntarily getting out of bed. There was no mention on the form of the resident's recent unwitnessed falls from his bed on 12/16/16 and 1/18/17. A note written in the comment section stated, IDT (interdisciplinary team) recommends 2 1/2 BSR (bed side rails) to aide (with) positioning + mobility. A physician's orders [REDACTED]. There was no assessment or mention of the marked section on the form indicating the rails were used to keep the resident from getting out of bed. Resident #5 experienced additional falls from his bed on 1/23/17, 2/4/17 and 2/10/17. The facility's investigation forms documented the following concerning these falls. 1/23/17 - resident seen crossing the hall walking carry (carrying) diaper, resident got startled fell back against the wall and slid down .resident got up without help . 2/4/17 - CNA called to nurse accident in floor. Alarm not sounding, Res (resident) rolled up in blanket lying on right side in floor next to bed in fetal position, incont. (incontinent) of BM (bowel movement) .Alarm intact/on started to Alarm as we were working (with) resident .educated Res. to use call bell .gait weak/unsteady .confused Dementia . 2/10/17 - Resident observed sitting upright beside bed .Alarm did not sound .Resident wears glasses, needs assistance w/ ADL's (with activities of daily living) socks were not slip resistant, side rails was still in up position, call bell in reach, resident alert to name . Facility investigations made no mention of the resident's continued side rail use after the additional falls on 1/23/17, 2/4/17 and 2/10/17. The forms marked side rails were not a factor in the falls even though the falls were unwitnessed and the resident got out of the bed without assistance prior to falling. Resident #5's care plan (revised 2/10/17) listed the resident was at risk for falls due to weakness, a history of falls and use of psychotropic medications. Interventions for fall/injury prevention included verbal reminders for resident not to ambulate/transfer without assistance, a toileting schedule, glasses on resident when awake, bed wheels locked at all times, low bed position, bed alarm and foot board on bed. The care plan listed use of bilateral 1/2 length bed rails as an intervention to prevent skin breakdown and improve mobility but included no problems, goals and/or interventions related to use of the side rails. On 2/28/17 at 11:20 a.m. the licensed practical nurse (LPN #5) caring for Resident #5 was interviewed about his use of side rails. LPN #5 stated the floor nurses usually completed the side rail assessment forms to evaluate if the resident was safe to have bed rails. When asked about responses on Resident #5's assessment dated [DATE] and the recommendation to use rails, LPN #5 stated she basically looked to see if the resident used the rails. LPN #5 stated Resident #5 held the rail when they were moving him in bed or turning him. LPN #5 stated the resident was not safe to get out of bed on his own and required assistance for toileting. On 2/28/17 at 2:20 p.m. the certified nurses' aide (CNA #5) caring for Resident #5 was interviewed. CNA #5 stated Resident #5 required the assistance of one person for transfer, bed mobility and toileting and the resident had a bed and chair alarm to alert staff if he got up unassisted. CNA #5 stated the side rails were raised when the resident was in bed and stated the resident held the rail when his brief was changed. CNA #5 stated the resident was not able to pull up on his own. On 2/28/17 at 3:00 p.m. the director of nursing (DON) was interviewed about Resident #5's use of side rails and the inaccurate, incomplete side rail assessment dated [DATE]. The DON stated concerning the responses on the 1/21/17 assessment, That's not right. The DON stated the responses concerning the resident's risk factors for entrapment and injury did not look correct. The DON stated, That form is confusing. Maybe we need a new form. The DON stated Resident #5 was not safe to get up on his own. When asked about continued use of the rails after the resident had experienced multiple, unassisted, unwitnessed falls from the bed, the DON stated, I need to watch him (Resident #5). Concerning the addition of the foot board to the bed, the DON stated they added that to keep him (Resident #5) from sliding out (of bed). On 2/28/17 at 3:25 p.m. the assistant director of nursing (ADON) was interviewed about Resident #5's side rail use and the risk assessment on 1/21/17. The ADON stated they completed the side rail assessments quarterly. The ADON stated the assessments were reviewed during their morning meeting with the interdisciplinary team. The ADON stated they usually looked to see if the residents were using the rails to increase their independence. When asked about the responses on Resident #5's assessment dated [DATE], the ADON stated the questions were not answered correctly. The ADON stated she had seen Resident #5 hold the rail to get to his bedside table and to get to his television remote. When asked about the resident falling after getting out of his bed with the side rails in place, the ADON stated, I need to re-assess him. The ADON stated the responses on the 1/21/17 assessment were not answered correctly as the resident was unable to safely go to the bathroom and transfer on his own. On 2/28/17 at 3:55 p.m. the administrator was interviewed about his knowledge of side rail use with Resident #5. The administrator stated the resident's wife wanted the side rails and the foot board was added to the resident's bed to assist with keeping him in bed. The administrator stated he was aware of the resident's fall history and interventions for Resident #5 included a low bed, alarms, the foot board and increased toileting. On 2/28/17 at 5:00 p.m. the staff development coordinator (LPN #3) presented a copy of a corrected side rail risk assessment for Resident #5 dated 2/28/17. The form listed the resident had multiple factors indicating a high risk for injury/entrapment that included his inability to safely transfer, inability to ambulate without falling, inability to use call bell system, altered safety awareness and history of falls. This form documented rails were not indicated and were removed from use. LPN #3 was interviewed at this time about the 1/21/17 risk assessment. LPN #3 stated the nurses usually completed the risk assessment forms and mostly looked at the resident's use of the rails during turning and repositioning or when care was provided. LPN #3 stated the responses Resident #5's risk assessment were not accurate as the resident was not able to safely transfer and the resident had a history of [REDACTED]. LPN #3 stated the risk assessment needed to include the resident's use of rails when unsupervised and take in to account the fall history and safety awareness. These findings were reviewed with the administrator and director of nursing during a meeting on 3/1/17 at 2:10 p.m. 4. Resident #8, with severe cognitive impairment and poor safety awareness, had bed side rails in use without an accurate assessment for safe use of the rails. Resident #8 was admitted to the facility on [DATE] with a re-admission on 7/31/16. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #8 with severely impaired cognitive skills. This MDS assessed Resident #8 as totally dependent upon one person for bed mobility, toileting and as totally dependent upon two people for transfers. On 2/28/17 at 2:00 p.m. Resident #8 was observed in bed with side rails raised on both sides of her bed. The rails was approximately 1/2 length of the bedside. The rails covered the section of the bedside from approximately 12 inches from the head of the bed to the center of the bedside. A pressure activated alarm was in place on the bed. Resident #8 was observed again on 2/28/17 at 4:00 p.m. in bed with the side rails up. The resident was on her right side and mumbling. Resident #8's clinical record documented a side rail risk assessment dated [DATE] indicating the resident was recommended to have 1/2 length bed side rails when in bed to aide in positioning and mobility. This assessment indicated the resident had only one out of four factors indicating a low risk of injury/entrapment and 5 of six factors indicating a high risk of injury/entrapment. The form listed side rails were indicated to provide safety but listed no medical conditions addressed by use of the rails. The form indicated the resident required 1/2 length rails instead of 1/4 length rails. The space for the resident's height and weight were blank. The clinical record documented the resident fell from her bed on 7/21/16 and fractured her femur but had experienced no further falls after a concave mattress and alarm were put in place. The resident's care plan (revised 1/5/17) listed the resident was at risk of falls due to balance problems, poor safety awareness and weakness. Interventions for falls included verbal reminders for the resident to not ambulate on her own, scheduled toileting, call bell, low bed position and bed wheels locked. Side rail use was listed as an intervention for the prevention of skin breakdown and to aide in bed mobility. On 2/28/17 at 3:00 p.m. the director of nursing (DON) was interviewed about how Resident #8 was safe to use side rails when her risk assessment indicated she was at high risk for injury/entrapment. The DON reviewed the form and stated the information entered did not look correct. The DON stated, That form is confusing. Maybe we need a new form. The DON stated Resident #8 was totally dependent upon staff for bed mobility and transfers. The DON stated the resident held the rail when being turned or during incontinence care. The DON stated she needed to look at the residents to see how they were actually using the rails. On 2/28/17 at 3:25 p.m. the assistant director of nursing (ADON) was interviewed and asked to explain the rationale for Resident #8 having side rails when the assessment indicated high risk factors for injury/entrapment. The ADON stated the nurses completed the risk assessments and looked to see if the resident was using the rails. When questioned about Resident #8's lack of low risk factors and 5 of six high risk factors for injury, the ADON stated she needed to re-assess Resident #8. The ADON stated Resident #8 mostly held the rail when she was turned and repositioned. On 2/28/17 at 5:00 p.m. the staff development coordinator (LPN #3) presented a copy of a corrected side rail risk assessment for Resident #8 dated 2/28/17. The form listed the resident had multiple factors indicating a high risk of injury/entrapment that included her inability to safely transfer, inability to ambulate without falling, inability to use call bell system, altered safety awareness and history of falls. This form documented rails were not indicated and were removed from use. LPN #3 was interviewed at this time about Resident #8's side rail use/assessment. LPN #3 stated the nurses completing the risk assessment were looking only at the resident's use of the rail during care. LPN #3 stated Resident #8 was totally dependent upon staff members for transfers and bed mobility and did not self-initiate movement with the rails. LPN #3 stated the assessments should include the resident's use of the rail when unsupervised. These findings were reviewed with the administrator and director of nursing during a meeting on 3/1/17 at 2:10 p.m. 5. Resident #12 did not have a chair alarm in use for fall prevention as required in her plan of care and had bed side rails in use without a completed assessment for safe use of the rails. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #12 with moderately impaired cognitive skills. a) Resident #12 did not have a chair alarm in use for fall prevention as required in her plan of care. On 3/1/17 at 9:30 a.m. Resident #12 was observed in her wheelchair in the dining room. There was no chair alarm in use at the time of this observation. On 3/1/17 at 9:45 a.m. Resident #12 was self-propelling in her wheelchair in the hallway going toward her room. There was no chair alarm in place on the resident's wheelchair. Resident #12's clinical record documented a physician's orders [REDACTED]. Resident #12's care plan (revised 2/28/17) listed the resident had a potential for falls due to balance/gait problems. Included among interventions to prevent injury from falls was, Alarm to bed/chair, tab alarm to chair, check every shift for function/placement. On 3/1/17 at 9:50 a.m. the certified nurses' aide (CNA #6) caring for Resident#12 was interviewed about the missing chair alarm. CNA #6 stated she did not usually work the day shift so she was not sure if the resident required a chair alarm. Accompanied by CNA #6, Resident #12 was observed in her wheelchair without use of a chair alarm. CNA #6 went to Resident #12's room and stated the alarm was still on the resident's bed. On 3/1/17 at 9:55 a.m. CNA #6 stated she checked with the nurse and Resident #12 was supposed to have a chair alarm when up in the wheelchair. On 3/1/17 at 10:30 a.m. the licensed practical nurse (LPN #5) caring for Resident #12 was interviewed about the alarm. LPN #5

Based on staff interview, resident interview and clinical record review, the facility staff failed to assess and provide treatments for the prevention of an unstageable pressure ulcer, which resulted in harm for one of eighteen residents in the survey sample, Resident #7. Resident #7 was not assessed or provided treatment to prevent the development of an unstageable pressure ulcer, which required debridement (surgical removal of necrotic tissue from a wound bed). The findings include: Resident #7 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/16/17 was a quarterly assessment. The resident was assessed as a ten (10) moderately impaired in decision-making skills. On 2/28/17 at approximately 8:00 a.m., Resident #7 was observed in her room and in bed. A resident interview was conducted with the resident's permission. During the interview, when asked if the staff provided care in a timely manner, Resident #7 stated, sometimes I get help in a timely manner and sometimes I have to wait a long time before they (staff) lay me back down. On 2/28/17 at approximately 2:00 p.m., Resident #7's current, February 2017, physician's orders [REDACTED]. On 2/28/17 at approximately 2:10 p.m., a Braden Scale (For predicting Pressure Sore Risk) form was reviewed to include the following: Severe Risk: Total Score <9 .High Risk: Total Score 10-12 .Moderate Risk: Total score 13-14 .Mild Risk: Total score 15-18 .Dates of Assessments 10/21 and 1/10, the resident was assessed as being a 13 (Moderate risk). On 2/28/17 at approximately 2:15 p.m., the Skin Assessments were reviewed in the clinical record. The Skin Assessments were reviewed to include the following: Weekly Skin Assessment Record Instructions: To be completed by a licensed nurse. Circle each area of impaired skin integrity / wound location on the diagram and write a descriptive note for each wound. Use on Weekly Assessment box each week and indicate multiple areas of impaired skin integrity/ wounds on each diagram. The Weekly Assessments were performed on the following days . 2/6/17 Area mid-back tx (treat) with NS (normal saline) Apply [MEDICATION NAME] Blue and cover with coversite daily . 2/13/17 Area to mid-back tx (treatment) in place. No new areas of impairment . On 2/28/17 at approximately 2:25 p.m., a Progress Note from the wound doctor was reviewed to include the following: 2/14/17 Note: After initial visit today nursing staff notified me of new wounds. Pt (patient) with new wound left buttock 9 x 5 cm (centimeters) and right buttock 6 x 5 cm (centimeters) unstageable necrosis. No current dressing. Dressing to be applied is Santyl and dry dressing daily. A Wound Care Specialist Evaluation note was reviewed to include the following: 2/21/17 Unstageable (Due to Necrosis) of the Left Buttock .Etiology: Pressure .MDS 3.0 Stage: Unstageable Necrosis .Objective: Manage Pain .Wound Size: 7 x 5 x 0.2 cm .Procedure: Surgical Excisional Debridement of (Site 2) Indication: Remove necrotic tissue and establish the margins of viable tissue .Description: The wound was cleansed with normal saline and anesthesia was achieved using 1% [MEDICATION NAME]. Then with clean surgical technique, curette was used to surgically excise 17.5 cm (squared) of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. Hemostasis was achieved and a clean dressing was applied The same was performed on the right buttock. On 2/28/17 at approximately 2:38 p.m., the nurse on the unit, who was a licensed practical nurse and will be identified as LPN #1 was interviewed regarding the unstageable pressure areas found on the resident's buttocks. LPN #1 stated, I did not see an area on her buttocks. We do the treatment on her mid-back and because the brief is so high we pull it (the brief) down. LPN #1 further stated, I saw something on her buttocks but it looked like excoriation. When interviewed and asked if the physician was made aware, LPN #1 stated, No. On 2/28/17 at approximately 2:45 p.m., the Certified Nursing Assistant (CNA), who was caring for the resident and will be identified as CNA #1 was interviewed regarding the unstageable pressure areas on the resident's buttocks. CNA #1 stated I saw the area on (Resident named) buttocks and I reported it to (Nurse named) and she (LPN #1) told me to put cream on it. CNA #1 stated, I was already doing that. On 2/28/17 at approximately 2:47 p.m., CNA # 1 was interviewed and asked if LPN #1 looked at the area after she was made aware, CNA #1 stated, She looked at it but she just told me to put cream on it and that's what I did but it slowly got worse (sic). When interviewed and asked when the pressure area was reported to LPN #1, CNA #1 stated, it was around mid-January or towards the end of January. On 2/28/17 at approximately 2:50 p.m.,the Assistant Director of Nursing (ADON) was interviewed regarding the pressure areas on the resident's buttocks being found at an unstageable. The ADON stated, It was not reported until February 14, when the wound doctor looked at it. I informed the Director of Nursing (DON) and I gave her the names of all staff caring for her (the resident). The wound doctor and myself looked at it at the same time. The wound doctor cauterized the area and it's healing now. A care plan (CP) revised on 1/19/17 was reviewed to include the following: Problem Onset 10/21/16 Resident with self care deficit due to functional limitations r/t (related to) [DIAGNOSES REDACTED], Is incontinent .Approaches: Observe skin daily during ADL (activities of daily living) care for changes, report changes observed in skin to nurse for follow up and treatment if needed / indicated . On 2/28/17 at approximately 5:22 p.m., the administrative staff was made aware of the above findings. No further information was presented to this Surveyor during the course of the survey, regarding the wounds on the resident's buttocks being found at an unstageable pressure ulcer.

Based on observation, staff interview and clinical record review, the facility staff failed to maintain acceptable parameters of nutritional status for one of 11 residents, Resident #110. The facility staff failed to identify that the resident preferred and accepted fluids; failed to ensure the resident received and consumed nutrition supplements; and failed to accurately document and assess the resident's supplement intake. As a result, Resident #110 experienced a ongoing significant weight loss of 17 pounds for a total loss of 17% of her body weight from the first week of January until 03/11/2014. Findings were: Resident #110 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE] with the following diagnoses, but not limited to: Depression, [MEDICAL CONDITION], anxiety, [MEDICAL CONDITION], hypertension, adult failure to thrive, and altered mental status. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 02/28/2014. Resident #110 was assessed as having a cognitive summary score of "3", indicating severe impairment with her cognitive status. On 03/12/2014 at approximately 8:20 a.m., Resident #110 was observed. She was self propelling her wheelchair with her feet near the nurse's station on the west wing of the facility. She kept her knees held together as she self-propelled. This surveyor observed a red colored object between her knees. Resident #110 propelled up to this surveyor and stated, "Will you wipe my nose?" CNA (certified nursing assistant) #3 over heard the resident and brought a tissue over to wipe her nose. CNA #3 was asked what Resident #110 was holding between her knees. CNA #3 reached between Resident #110 knees and handed this surveyor an unopened/sealed container. The lid read, "[MEDICATION NAME] Calorie and Protein Food Enhancer." CNA #3 was asked where Resident #110 had gotten the container. She stated, "I don't know, I have never seen her with that before...it is always locked on the nurse's cart...the nurse's give it to her." This surveyor then took the [MEDICATION NAME] to the mediation nurse, RN (registered nurse) #1. RN #1 was asked if she was giving medications to Resident #110. She stated, "Yes." RN #1 was shown the container of [MEDICATION NAME] and was asked why Resident #110 had the container between her knees. She stated, "I gave it to her...it's just a supplement...I give it to her and she takes it to the dining room, they put it in her breakfast and then they let me know how much of it she takes." RN #1 was asked if the [MEDICATION NAME] was on the MAR (medication administration record). She stated, "Yes...but it is just a supplement, it really isn't a medication." RN #1 was asked if the normal process at the facility was for the [MEDICATION NAME] to be given to the residents to take to the dining room. She stated, "I don't know, it is just a supplement." RN #1 was asked if Resident #110 was cognitively intact. She stated, "She is confused." A copy of the MAR was requested. A copy of the MAR was received. Observed on the MAR were the following entries with dosage times were observed: "[MEDICATION NAME] by mouth three times daily-supplement 0900, 1300, 1700; Med pass 120 cc (4 oz) by mouth three times daily-supplement 0900, 1300, 1700 and Carnation Instant Breakfast by mouth three times daily with lunch, dinner and at bedtime 1300, 1700, 2100." All three supplements were initialed by RN #1 for the dosage times of 0900 and 1300. This surveyor and the ADON (assistant director of nursing) approached RN #1 about the entries. RN #1 stated, "They are just supplements...I go ahead and sign them off in the mornings to save time. I write down over here on this piece of paper (pointed to a paper on the medication cart) that I need to follow up and see how much she took...if she doesn't take it then I circle it...I don't do that with my medicines but I am a little more careless with the supplements...I do it to save time." The ADON was asked if this was the expected process for signing out the supplements. She stated, "I don't do it that way...I give them to her and make sure she has taken them before I sign them out...I feed her and she does well for me, she takes liquids with no problem" The ADON was asked if signing out the supplements prior to their administration was acceptable. She stated, "No.." She then addressed RN #1 and stated, "You shouldn't do it like that." This surveyor then went to the small dining room, which was an area off of the main dining room designated for residents who needed assistance with eating. CNA #8 was in the dining room and was interviewed. CNA #8 was asked if Resident #110 ate in the small dining room. She stated, "Yes." CNA #8 was asked if Resident #110 or other residents brought their supplements with them to the dining room. She stated, "Sometimes." She was asked if she had ever assisted Resident #110 with her [MEDICATION NAME]. She stated, "Yes, I mix it in her oatmeal or her milk and she takes it..." CNA #8 was asked how that information was communicated to the medication nurse. She stated, "Sometimes they ask me, sometimes I go tell them, sometimes I write it on the ticket (meal ticket)." This surveyor then went to the nurse's station to obtain Resident #110's clinical record. The record was not stored on the chart rack but was located in a different area of the nurse's station. The ADON assisted this surveyor in finding the clinical record. The ADON was asked why some of the records were stored in a separate area. She stated, "She has a 'hot chart'." The ADON was asked what that meant. She stated, "The 'hot charts' are residents that we are watching closer and documenting on more often." The ADON was asked why Resident #110 was in that category. She stated, "She is a weight loss." The clinical record was reviewed beginning at approximately 9:30 a.m. Observed in the dietary section of the clinical record were the following entries: A dietary progress note signed by the registered dietitian (RD): "02/25/14 Wt down to 94 pounds at beginning month. This week, wt down to 87 pounds. PO (by mouth) is poor. Resident discussed in QA meeting today. Resident drinks better than she eats food. Recent antibiotic treatment for [REDACTED]. High risk skin breakdown. Wt loss and dehydration secondary to poor PO intake. Multiple interventions in place to increase calories including Carnation breakfast, Med Pass, [MEDICATION NAME], Super Cereal, whole milk, ice cream. Shakes TID added today to try to increase po intake. Resident refuses to be fed. Refusal dietary interventions by resident. Goal: Halt wt loss if possible. Encourage increased po intake. Offer high calorie fluids/supplements. Monitor with QA team." A dietary progress note signed by the RD: "02/28/2014 See unavoidable wt loss form. [MEDICATION NAME] initiated. MD aware of wt loss. See MD note 02/26/2014. Unavoidable wt loss due to resident refusal to eat and refusal of dietary interventions." A note in the physician's progress section read: "02/26/2014 Weight loss review not eating but drinking. Weight is down to 87 pounds...wt loss. Try [MEDICATION NAME] 30 mg PO HS." Observed in the physician order [REDACTED]. D/C [MEDICATION NAME] 30 mg PO QHS". A form titled "...Clinically Unavoidable Weight Loss Form" was observed in the clinical record. The form was dated 02/26/2014 and contained the following information: Qualifying Criteria: Refusal to eat or refusal of other prescribed nourishment...What measures have been attempted to address weight loss and the resident response: Health shakes TID with meals, carnation instant breakfast TID, med pass 120 TID, [MEDICATION NAME] TID, [MEDICATION NAME] 15 mg PO QHS. Social Service Note: ...Resident had a change in mental status. Family informed of change in mental status by nursing staff per documentation. Dietary Notes: Multiple interventions in place to increase calories including shakes, instant breakfast, [MEDICATION NAME], med pass supplement, super cereal, whole milk, ice cream, etc. Resident reuses to be fed. Refusal to eat and of dietary supplements..." The form was signed by the physician, the RD, and the DON. The nurse's note section was then reviewed. The following entries were observed from 02/12/2014 through 03/12/2014 regarding PO intake for Resident #110: "02/12/2014...Fair PO intake for breakfast... 02/13/2014...Fluids encouraged 02/15/2014...Res takes meds, liquids well...Res fed by staff, appetite fair... 02/16/2014...Res fed by staff, appetite poor. Res takes meds and liquids well. Res on ATB (antibiotic) tx for UTI... 02/17/2014...PO fluids offered... 02/18/2014 Accepted 1 cup of water -no problems with swallowing noted... 02/18/2014 1300 Took 300 cc of juice and lemmonade (sic) PO... 02/18/2013 2200 No po intake this evening... 02/20/2014 ...will continue to encourage po fluids as she will allow... 02/20/2014... Res takes meds, liquids well. Res fed by staff, appetite fair to poor... 02/21/2014 ...Res fed by staff, refused dinner tonight. Res takes meds and liquids well... 02/22/2014 fed breakfast - ate 50 percent, PO fluids encouraged and at lunch not much food drank 188 cc. 02/22/2014 1900...In evening meal accepted bites only, fed by staff. States, "I don't want it." Fluids encouraged... 02/23/2014 Refused food, ate only a few bites- did drink her Carnation Instant milkshake..at lunch refused food and fluids. 02/23/2014 1900 Accepted bites only of evening meal, stated, "I'm not hungry," Accepted 50 percent of milk and ice cream... 02/24/2014 PO intake continues to be very poor...she is drinking her Carnation Instant breakfast and med pass 02/24/2014 Drank a cup of smoothie... 02/24/2014 Refused evening meal. Accepted smoothie and water... 02/25/2014 0800 accepted meds and two glasses of smoothies. Wouldn't eat other food. Took med pass... 02/25/2014 QA meeting held. Weight was 87 lbs. Will continue weekly weights. Will add health shakes TID with meals. Will discuss unavoidable weight loss with MD tomorrow. 02/25/2014 2150 ...Res fed by staff, appetite poor, ate 25 % of dinner. Res took meds, liquids well... 02/26/2014 1000 ..N.O. (new order) received to help increase appetite...little to no po intake with breakfast...fluids encouraged... 02/26/2014 Accepted 25 % evening meal, fed by staff. Fluids encouraged... 02/27/2014 In dining room for evening meal, refused to eat. stated, "I don't want it:..." 02/28/2014 She is not eating or drinking well, refuses. Does drink Med pass and take po medication crushed with applesauce. 02/28/14 Refused to feed self and refused to be fed evening meal... 03/01/2014 ... Res fed by staff, appetite poor... 03/02/2014 Ate 25 % for breakfast and lunch, fluids encouraged and tolerated well. 03/02/2014 Res refused dinner tonight, took meds and liquids well... 03/03/2014...not eating, will drink with a lot of encouragement 03/03/2014 Resident accepted all medication with no difficulty. Accepted 240 ml with med pass. Accepted some mashed potatoes, peas and 240 ml of milk... 03/04/2014 ...to dining room for evening meal. Accepted 50 %, fed by staff. Accepted liquids. 03/06/2014 ... Res fed by staff, appetite fair, ate 50 % of dinner, took 460 ml of fluids. Took meds, liquids well... 03/07/2014...accepted meds and med pass, refused breakfast... 03/07/2014 ...Res took meds, liquids well. Res fed by staff, appetite poor, ate 25% of dinner, took 340 ml of liquids... 03/08/2014 Continues to not eat, will drink with fluids offered freq. 03/08/2014...to dining room for evening meal, accepted bites only with encouragement. Fed by staff, accepted 360 ml liquids. 03/09/2014 Accepted bites of evening meal, fed by staff. Fluids encouraged... 03/11/2014 Resident fed by staff. accepted bites of meal Fluids encouraged..." At approximately 10:30 a.m., the ADON was interviewed regarding PO intake for Resident #110. The ADON stated, "We do it a couple of ways." The ADON obtained a "Hydration Book" and stated, "We write down what she eats and drinks in here and on the ADL sheet...the numbers on this paper indicate how much she ate...a 1 is 25 percent, a 2 is 50, a 3 is 75, and a 4 means she ate 100 percent, the 5's mean that she refused...the numbers are the same on the ADL sheet, but they only track food intake, not the amount of liquids." The ADON was asked how the liquid information was communicated from the dining room to the nurse's station be recorded in the hydration book. She stated, "They write it on the meal tray ticket." The ADON was asked who "They" referred to. She stated, "The CNA or whoever feeds her." The ADON was asked if Resident #110's ticket was at the nurse's station from the morning meal. The ADON and this surveyor went to the nurse's station. The breakfast meal ticket was located. Written on the ticket in a column were the following numbers: 60, 30, 120, 110 and a line was drawn with the number 290 written. The ADON was asked what the numbers meant. She stated, "I think that is the amount of fluid she had at breakfast." RN #1 was standing at the nurse's station. She stated, "I started feeding her this morning and then (name of staff) took over...that 290 is the total for breakfast, but that's not right..." RN #1 was asked what the numbers referred to. She stated, "The 60 and the 30 is her med pass...I gave her 60 cc and then 30 cc..." RN #1 was asked why Resident #110 was given 90 cc total of med pass when the order was for 120 cc. She stated, " Yes, I am going to go give her some more...Wait...oh that's right, I poured it in a cup...she did get 120 cc...the total on there isn't correct." RN #1 then marked through the numbers on the meal ticket and wrote down the number 350. She stated, "That's what it should be." Copies of the hydration log and the ADL sheets for Resident #110 from 02/14/2014 through 03/12/2014 were requested, as well as the MAR for February. The MAR for February and March were reviewed. The supplements ordered fro Resident #110 were signed off as given every day. There was no documentation on the MAR or within the nurse's notes indicating that Resident #110 had ever refused any of her supplements. Copies of the hydration logs were received. The logs were divided into the areas of breakfast, lunch and dinner. Each area contained spaces to document fluid and hydration. There were no logs presented for 02/14, 02/15, 02/19, 02/23, or 03/06. For the 19 days provided, 12 days did not contain documentation of Resident #110's intake for all three meals of the day. The ADL sheets for February did not have meal intake documented for all three meals for eight days. All other days were marked to indicate that Resident #110 had either eaten 25 % of the meal or had refused. For the month of March one day did not have all three meals documented. The ADON came to the conference room at approximately 11:45 a.m., to speak with this surveyor about Resident #110's intake as documented on the logs provided. The ADON was asked if she felt Resident #110's intake was accurately captured on the logs. She stated, "I understand what you are looking at...the bad thing is that the numbers you see on the ADL sheets only record her food...the numbers do not take into account the amount of fluid she drinks...they are suppose to write that down so we can record it...I know that she drinks what we give her, because I am here and I feed her...but I take my time with her...I can only go by what is written down on here..." The ADON was asked about the documentation on the MARS regarding the supplements. The ADON was asked if the initials on each pass time indicated the supplements had been given. She nodded her head "yes". The ADON was asked how it would be documented if Resident#110 did not take the supplements. She stated, "It would be circled." On 03/12/2014 at approximately 12:15 p.m., Resident #110 was observed in the dining room. RN #1 asked one of the surveyors, "Did you all bring her in here and put her at the table?" The surveyor responded, "No." RN # 1 stated. "She is a feeder. CNA #1 who was sitting at a table assisting another resident stated, "She is? I didn't know that." RN #1 then took Resident #110 out of the dining room and then returned a few minutes later. RN #1 pushed Resident #110 up to the table in the dining room. RN #1 stated, "Would it be rude if I sat here and fed her?" RN #1 then began to feed Resident #110. This surveyor observed Resident #110's tray. Fluids on the tray were a carton (240 cc) of whole milk and a carton (120 cc) of healthy shake. RN #1 stated, "I mixed her Instant Breakfast in with her milk...she drinks fluids really well." RN #1 was asked what the total fluid content was for Resident #110 for lunch. She stated, "what's here plus her Benecal that I mixed in, it's 44 cc...she also got her med pass which was 120 cc." This surveyor stated, " So a little over 500 cc?" RN #1 stated, "Yes." RN #1 was asked what the caloric content of the fluids on Resident #110's tray was. She stated, "The shake is 200 calories, the milk is 150, the benecal is 330, and the Instant breakfast is 60...it's sugar free, I don't know why they give her sugar free, she isn't a diabetic and she loves sweets...if it is sweet she takes it with no problem...I don't' know what the med pass was." At approximately 12:30 p.m., two CNAs were interviewed about feeding Resident #110. CNA #1 was interviewed. CNA #1 stated that she had been at the facility for approximately three years and stated that she regularly was in the dining room during meal time. CNA #1 was asked about feeding Resident #110. She stated, "Well, I thought she was an assist...you know, we let her do what she can do and then we jump in to help her." CNA #1 was asked how often staff needed to"jump in". She stated, "Probably every meal...I just didn't know she was a total feeder until today." CNA #14 was also interviewed. CNA #14 stated, "She usually feeds herself..some days she won't and then we feed her...if she sits for a couple of minutes and doesn't do anything we feed her." CNA #14 was asked how much Resident #110 usually ate at meals. She stated, "She doesn't eat much, but she will drink all of her liquids." This surveyor spoke with RN #1 at approximately 1:00 p.m., at the nurse's station. RN #1 was asked if Resident #110 had consumed all of the liquids on her tray at lunch time. She stated "Yes." The care plan was then reviewed. A problem area dated 09/24/2013 was: "Resident for potential for alteration in nutritional status due to leaves 25 percent or more of most meals on tray and recieves (sic) theraputic (sic) diet as ordered." Approaches included but were not limited to: "Milk X 3, extra ice cream with lunch and dinner meals, monitor and record intake daily, feeds self after set up @ X's (times) does not assist as needed and encourage, carnation instant breakfast shake, 1 packet mixed with whole carton of whole milk and ice cream, lunch, dinner and HS, [MEDICATION NAME] TID (12/3/13), RNP for eating (1/14/14)..., med pass 120 cc TID (12/3/13), health shake TID with meals (2/25/14), unavoidable weight loss to be completed by MD/nrsg/RD (2/25/14)." Weights recorded on the care plan included: 12/10/13 96 pounds 12/17/13 97 pounds 12/24/13 99 pounds 12/31/13 98 pounds 01/07/14 100 pounds [DATE] pounds [DATE] pounds down 6 pounds 2/25/14 87 pounds 3/4/14 85 pounds 3/11/14 83 pounds The DM (dietary manager) came to the conference room on 03/12/2014 at approximately 1:20 p.m. to speak with this surveyor. The DM was asked about the Unavoidable weight loss form and the documentation regarding Resident #110's refusal of "dietary interventions." The DM stated, "I would prefer you talk to (name of RD) about what that means, that is her note...I don't want to speculate..." The DM was asked about the "Super cereal" listed in the RD's notes. She stated, "We don't need an order for [REDACTED]." On 03/12/2014 at approximately 2:12 p.m., the DON (director of nursing) was interviewed regarding Resident #110's weight loss. The DON stated, "We get weights on everyone monthly...the weights are done and go to the ADON, the ADON reviews the weights and determines if the weights are accurate of if she thinks the resident should be reweighed...they have until the fifth of each month to get the weights, do any reweighs and get the weights to me...I put them in the computer..we discuss any weight loss at the QA meetings...I put copies of the monthly weights in both ADON's, the DM, and the administrator's mail box...what should have happened is the weight loss for (Resident #110) should have been picked up on and brought to me before I ever got the list of weights...I should have been told that we had an issue...the print out of weights went out on 2/10 to discuss in QA on 2/11, we didn't pick it up, it fell through the cracks...the RD picked up on it when she looked at the weights and she emailed me that we should put her back on weekly weights, that was on 2/25 and she weighted 87 pounds..it just fell through the cracks, there is plenty of blame to go around on this one." The RD was interviewed via telephone on 03/12/2014 at approximately 3:40 p.m. This surveyor explained to the RD that the survey team had questions regarding her role at the facility and about (Name of Resident #110). The RD stated that she did not have any notes with her regarding Resident #110 but that she would discuss what she could. The RD was asked about her role at the facility. She stated, "I am at the facility eight hours per month, I concentrate on the high risk residents when I am there, wt loss, tube feedings and skin breakdowns." The RD was asked if she attended QA meetings at the facility. She stated, "No, the DM sits in on the weekly QA meetings and she and the DON relay anything to me that needs to be addressed." The RD was asked how she is made aware of weight losses at the facility. She stated, "I get a monthly weight report, it is either emailed to me or is in my mailbox at the facility." The RD was asked about the unavoidable weight loss form that had been completed for Resident #110. The RD was reminded that the form stated Resident #110's weight loss was due tot he resident's refusal to eat and refusal of dietary interventions." The RD was asked what the entry "Refusal of dietary interventions meant." She stated, "She is refusing to drink her supplements...if you don't eat and you don't take your supplements you are going to lose weight." The RD was asked how she had obtained information that Resident #110 had refused her dietary supplements. She stated, "From the staff." The RD was asked if she looked at the MARs for Resident #110 which document her daily supplements. She stated, "Sometimes, but I didn't this time." The RD was told that per the MAR and staff interview, Resident#110 takes her supplements every day, each time they are offered. The RD asked if the initials on the MAR indicated the supplements had been given to her to take or did the initials indicate that the supplements had been given to her to take and she actually drank them. The RD was told that per staff interview, the initials indicated that Resident #110 had been given the supplements and she had taken them. If she had not consumed them the initials would have been circled. The RD was then asked if the weight loss would still be considered "Unavoidable". She stated, "That is a good point, with the information that I had it was unavoidable if she was refusing her supplements...if she is taking her supplements then I would say it is not unavoidable...that really doesn't make sense..I was under the impression that she was not taking them consistently and was consequently losing weight...I guess if she is taking 100 percent of her supplements and continues to lose weight we need to increase her supplements to get more calories in her..." The RD was asked why no interventions were implemented with the weight loss of six pounds recorded the first week of February. She stated, "Sometimes it is the middle of the month before I get the monthly weights... I don't always get them in a timely manner, sometimes it is the middle of the month and not the beginning of the month when I get them, so they are already a couple of weeks out...that's what happened with her...when I saw the weight loss of six pounds, I emailed the DON and asked for the resident to be put on weekly weights so we could monitor her...then the weight was down more so we added the healthy shake and the doctor added the [MEDICATION NAME]" An end of the day meeting was held with the administrator, the DON, and the ADON on 03/12/2014 at approximately 4:40 p.m. The above information was discussed. No further information was obtained prior to the exit conference on 03/12/2014.

Based on observation, staff interview and clinical record review, the facility staff failed to maintain acceptable parameters of nutritional status for one of 11 residents, Resident #110. The facility staff failed to identify that the resident preferred and accepted fluids; failed to ensure the resident received and consumed nutrition supplements; and failed to accurately document and assess the resident's supplement intake. As a result, Resident #110 experienced a ongoing significant weight loss of 17 pounds for a total loss of 17% of her body weight from the first week of January until 03/11/2014. Findings were: Resident #110 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE] with the following diagnoses, but not limited to: Depression, [MEDICAL CONDITION], anxiety, [MEDICAL CONDITION], hypertension, adult failure to thrive, and altered mental status. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 02/28/2014. Resident #110 was assessed as having a cognitive summary score of 3, indicating severe impairment with her cognitive status. On 03/12/2014 at approximately 8:20 a.m., Resident #110 was observed. She was self propelling her wheelchair with her feet near the nurse's station on the west wing of the facility. She kept her knees held together as she self-propelled. This surveyor observed a red colored object between her knees. Resident #110 propelled up to this surveyor and stated, Will you wipe my nose? CNA (certified nursing assistant) #3 over heard the resident and brought a tissue over to wipe her nose. CNA #3 was asked what Resident #110 was holding between her knees. CNA #3 reached between Resident #110 knees and handed this surveyor an unopened/sealed container. The lid read, [MEDICATION NAME] Calorie and Protein Food Enhancer. CNA #3 was asked where Resident #110 had gotten the container. She stated, I don't know, I have never seen her with that before.it is always locked on the nurse's cart.the nurse's give it to her. This surveyor then took the [MEDICATION NAME] to the mediation nurse, RN (registered nurse) #1. RN #1 was asked if she was giving medications to Resident #110. She stated, Yes. RN #1 was shown the container of [MEDICATION NAME] and was asked why Resident #110 had the container between her knees. She stated, I gave it to her.it's just a supplement.I give it to her and she takes it to the dining room, they put it in her breakfast and then they let me know how much of it she takes. RN #1 was asked if the [MEDICATION NAME] was on the MAR (medication administration record). She stated, Yes.but it is just a supplement, it really isn't a medication. RN #1 was asked if the normal process at the facility was for the [MEDICATION NAME] to be given to the residents to take to the dining room. She stated, I don't know, it is just a supplement. RN #1 was asked if Resident #110 was cognitively intact. She stated, She is confused. A copy of the MAR was requested. A copy of the MAR was received. Observed on the MAR were the following entries with dosage times were observed: [MEDICATION NAME] by mouth three times daily-supplement 0900, 1300, 1700; Med pass 120 cc (4 oz) by mouth three times daily-supplement 0900, 1300, 1700 and Carnation Instant Breakfast by mouth three times daily with lunch, dinner and at bedtime 1300, 1700, 2100. All three supplements were initialed by RN #1 for the dosage times of 0900 and 1300. This surveyor and the ADON (assistant director of nursing) approached RN #1 about the entries. RN #1 stated, They are just supplements.I go ahead and sign them off in the mornings to save time. I write down over here on this piece of paper (pointed to a paper on the medication cart) that I need to follow up and see how much she took.if she doesn't take it then I circle it.I don't do that with my medicines but I am a little more careless with the supplements.I do it to save time. The ADON was asked if this was the expected process for signing out the supplements. She stated, I don't do it that way.I give them to her and make sure she has taken them before I sign them out.I feed her and she does well for me, she takes liquids with no problem The ADON was asked if signing out the supplements prior to their administration was acceptable. She stated, No. She then addressed RN #1 and stated, You shouldn't do it like that. This surveyor then went to the small dining room, which was an area off of the main dining room designated for residents who needed assistance with eating. CNA #8 was in the dining room and was interviewed. CNA #8 was asked if Resident #110 ate in the small dining room. She stated, Yes. CNA #8 was asked if Resident #110 or other residents brought their supplements with them to the dining room. She stated, Sometimes. She was asked if she had ever assisted Resident #110 with her [MEDICATION NAME]. She stated, Yes, I mix it in her oatmeal or her milk and she takes it. CNA #8 was asked how that information was communicated to the medication nurse. She stated, Sometimes they ask me, sometimes I go tell them, sometimes I write it on the ticket (meal ticket). This surveyor then went to the nurse's station to obtain Resident #110's clinical record. The record was not stored on the chart rack but was located in a different area of the nurse's station. The ADON assisted this surveyor in finding the clinical record. The ADON was asked why some of the records were stored in a separate area. She stated, She has a 'hot chart'. The ADON was asked what that meant. She stated, The 'hot charts' are residents that we are watching closer and documenting on more often. The ADON was asked why Resident #110 was in that category. She stated, She is a weight loss. The clinical record was reviewed beginning at approximately 9:30 a.m. Observed in the dietary section of the clinical record were the following entries: A dietary progress note signed by the registered dietitian (RD): 02/25/14 Wt down to 94 pounds at beginning month. This week, wt down to 87 pounds. PO (by mouth) is poor. Resident discussed in QA meeting today. Resident drinks better than she eats food. Recent antibiotic treatment for [REDACTED]. High risk skin breakdown. Wt loss and dehydration secondary to poor PO intake. Multiple interventions in place to increase calories including Carnation breakfast, Med Pass, [MEDICATION NAME], Super Cereal, whole milk, ice cream. Shakes TID added today to try to increase po intake. Resident refuses to be fed. Refusal dietary interventions by resident. Goal: Halt wt loss if possible. Encourage increased po intake. Offer high calorie fluids/supplements. Monitor with QA team. A dietary progress note signed by the RD: 02/28/2014 See unavoidable wt loss form. [MEDICATION NAME] initiated. MD aware of wt loss. See MD note 02/26/2014. Unavoidable wt loss due to resident refusal to eat and refusal of dietary interventions. A note in the physician's progress section read: 02/26/2014 Weight loss review not eating but drinking. Weight is down to 87 pounds.wt loss. Try [MEDICATION NAME] 30 mg PO HS. Observed in the physician order [REDACTED]. D/C [MEDICATION NAME] 30 mg PO QHS. A form titled .Clinically Unavoidable Weight Loss Form was observed in the clinical record. The form was dated 02/26/2014 and contained the following information: Qualifying Criteria: Refusal to eat or refusal of other prescribed nourishment.What measures have been attempted to address weight loss and the resident response: Health shakes TID with meals, carnation instant breakfast TID, med pass 120 TID, [MEDICATION NAME] TID, [MEDICATION NAME] 15 mg PO QHS. Social Service Note: .Resident had a change in mental status. Family informed of change in mental status by nursing staff per documentation. Dietary Notes: Multiple interventions in place to increase calories including shakes, instant breakfast, [MEDICATION NAME], med pass supplement, super cereal, whole milk, ice cream, etc. Resident reuses to be fed. Refusal to eat and of dietary supplements. The form was signed by the physician, the RD, and the DON. The nurse's note section was then reviewed. The following entries were observed from 02/12/2014 through 03/12/2014 regarding PO intake for Resident #110: 02/12/2014.Fair PO intake for breakfast. 02/13/2014.Fluids encouraged 02/15/2014.Res takes meds, liquids well.Res fed by staff, appetite fair. 02/16/2014.Res fed by staff, appetite poor. Res takes meds and liquids well. Res on ATB (antibiotic) tx for UTI. 02/17/2014.PO fluids offered. 02/18/2014 Accepted 1 cup of water -no problems with swallowing noted. 02/18/2014 1300 Took 300 cc of juice and lemmonade (sic) PO. 02/18/2013 2200 No po intake this evening. 02/20/2014 .will continue to encourage po fluids as she will allow. 02/20/2014. Res takes meds, liquids well. Res fed by staff, appetite fair to poor. 02/21/2014 .Res fed by staff, refused dinner tonight. Res takes meds and liquids well. 02/22/2014 fed breakfast - ate 50 percent, PO fluids encouraged and at lunch not much food drank 188 cc. 02/22/2014 1900.In evening meal accepted bites only, fed by staff. States, I don't want it. Fluids encouraged. 02/23/2014 Refused food, ate only a few bites- did drink her Carnation Instant milkshake.at lunch refused food and fluids. 02/23/2014 1900 Accepted bites only of evening meal, stated, I'm not hungry, Accepted 50 percent of milk and ice cream. 02/24/2014 PO intake continues to be very poor.she is drinking her Carnation Instant breakfast and med pass 02/24/2014 Drank a cup of smoothie. 02/24/2014 Refused evening meal. Accepted smoothie and water. 02/25/2014 0800 accepted meds and two glasses of smoothies. Wouldn't eat other food. Took med pass. 02/25/2014 QA meeting held. Weight was 87 lbs. Will continue weekly weights. Will add health shakes TID with meals. Will discuss unavoidable weight loss with MD tomorrow. 02/25/2014 2150 .Res fed by staff, appetite poor, ate 25 % of dinner. Res took meds, liquids well. 02/26/2014 1000 .N.O. (new order) received to help increase appetite.little to no po intake with breakfast.fluids encouraged. 02/26/2014 Accepted 25 % evening meal, fed by staff. Fluids encouraged. 02/27/2014 In dining room for evening meal, refused to eat. stated, I don't want it:. 02/28/2014 She is not eating or drinking well, refuses. Does drink Med pass and take po medication crushed with applesauce. 02/28/14 Refused to feed self and refused to be fed evening meal. 03/01/2014 . Res fed by staff, appetite poor. 03/02/2014 Ate 25 % for breakfast and lunch, fluids encouraged and tolerated well. 03/02/2014 Res refused dinner tonight, took meds and liquids well. 03/03/2014.not eating, will drink with a lot of encouragement 03/03/2014 Resident accepted all medication with no difficulty. Accepted 240 ml with med pass. Accepted some mashed potatoes, peas and 240 ml of milk. 03/04/2014 .to dining room for evening meal. Accepted 50 %, fed by staff. Accepted liquids. 03/06/2014 . Res fed by staff, appetite fair, ate 50 % of dinner, took 460 ml of fluids. Took meds, liquids well. 03/07/2014.accepted meds and med pass, refused breakfast. 03/07/2014 .Res took meds, liquids well. Res fed by staff, appetite poor, ate 25% of dinner, took 340 ml of liquids. 03/08/2014 Continues to not eat, will drink with fluids offered freq. 03/08/2014.to dining room for evening meal, accepted bites only with encouragement. Fed by staff, accepted 360 ml liquids. 03/09/2014 Accepted bites of evening meal, fed by staff. Fluids encouraged. 03/11/2014 Resident fed by staff. accepted bites of meal Fluids encouraged. At approximately 10:30 a.m., the ADON was interviewed regarding PO intake for Resident #110. The ADON stated, We do it a couple of ways. The ADON obtained a Hydration Book and stated, We write down what she eats and drinks in here and on the ADL sheet.the numbers on this paper indicate how much she ate.a 1 is 25 percent, a 2 is 50, a 3 is 75, and a 4 means she ate 100 percent, the 5's mean that she refused.the numbers are the same on the ADL sheet, but they only track food intake, not the amount of liquids. The ADON was asked how the liquid information was communicated from the dining room to the nurse's station be recorded in the hydration book. She stated, They write it on the meal tray ticket. The ADON was asked who They referred to. She stated, The CNA or whoever feeds her. The ADON was asked if Resident #110's ticket was at the nurse's station from the morning meal. The ADON and this surveyor went to the nurse's station. The breakfast meal ticket was located. Written on the ticket in a column were the following numbers: 60, 30, 120, 110 and a line was drawn with the number 290 written. The ADON was asked what the numbers meant. She stated, I think that is the amount of fluid she had at breakfast. RN #1 was standing at the nurse's station. She stated, I started feeding her this morning and then (name of staff) took over.that 290 is the total for breakfast, but that's not right. RN #1 was asked what the numbers referred to. She stated, The 60 and the 30 is her med pass.I gave her 60 cc and then 30 cc. RN #1 was asked why Resident #110 was given 90 cc total of med pass when the order was for 120 cc. She stated, Yes, I am going to go give her some more.Wait.oh that's right, I poured it in a cup.she did get 120 cc.the total on there isn't correct. RN #1 then marked through the numbers on the meal ticket and wrote down the number 350. She stated, That's what it should be. Copies of the hydration log and the ADL sheets for Resident #110 from 02/14/2014 through 03/12/2014 were requested, as well as the MAR for February. The MAR for February and March were reviewed. The supplements ordered fro Resident #110 were signed off as given every day. There was no documentation on the MAR or within the nurse's notes indicating that Resident #110 had ever refused any of her supplements. Copies of the hydration logs were received. The logs were divided into the areas of breakfast, lunch and dinner. Each area contained spaces to document fluid and hydration. There were no logs presented for 02/14, 02/15, 02/19, 02/23, or 03/06. For the 19 days provided, 12 days did not contain documentation of Resident #110's intake for all three meals of the day. The ADL sheets for February did not have meal intake documented for all three meals for eight days. All other days were marked to indicate that Resident #110 had either eaten 25 % of the meal or had refused. For the month of March one day did not have all three meals documented. The ADON came to the conference room at approximately 11:45 a.m., to speak with this surveyor about Resident #110's intake as documented on the logs provided. The ADON was asked if she felt Resident #110's intake was accurately captured on the logs. She stated, I understand what you are looking at.the bad thing is that the numbers you see on the ADL sheets only record her food.the numbers do not take into account the amount of fluid she drinks.they are suppose to write that down so we can record it.I know that she drinks what we give her, because I am here and I feed her.but I take my time with her.I can only go by what is written down on here. The ADON was asked about the documentation on the MARS regarding the supplements. The ADON was asked if the initials on each pass time indicated the supplements had been given. She nodded her head yes. The ADON was asked how it would be documented if Resident#110 did not take the supplements. She stated, It would be circled. On 03/12/2014 at approximately 12:15 p.m., Resident #110 was observed in the dining room. RN #1 asked one of the surveyors, Did you all bring her in here and put her at the table? The surveyor responded, No. RN # 1 stated. She is a feeder. CNA #1 who was sitting at a table assisting another resident stated, She is? I didn't know that. RN #1 then took Resident #110 out of the dining room and then returned a few minutes later. RN #1 pushed Resident #110 up to the table in the dining room. RN #1 stated, Would it be rude if I sat here and fed her? RN #1 then began to feed Resident #110. This surveyor observed Resident #110's tray. Fluids on the tray were a carton (240 cc) of whole milk and a carton (120 cc) of healthy shake. RN #1 stated, I mixed her Instant Breakfast in with her milk.she drinks fluids really well. RN #1 was asked what the total fluid content was for Resident #110 for lunch. She stated, what's here plus her Benecal that I mixed in, it's 44 cc.she also got her med pass which was 120 cc. This surveyor stated, So a little over 500 cc? RN #1 stated, Yes. RN #1 was asked what the caloric content of the fluids on Resident #110's tray was. She stated, The shake is 200 calories, the milk is 150, the benecal is 330, and the Instant breakfast is 60.it's sugar free, I don't know why they give her sugar free, she isn't a diabetic and she loves sweets.if it is sweet she takes it with no problem.I don't' know what the med pass was. At approximately 12:30 p.m., two CNAs were interviewed about feeding Resident #110. CNA #1 was interviewed. CNA #1 stated that she had been at the facility for approximately three years and stated that she regularly was in the dining room during meal time. CNA #1 was asked about feeding Resident #110. She stated, Well, I thought she was an assist.you know, we let her do what she can do and then we jump in to help her. CNA #1 was asked how often staff needed tojump in. She stated, Probably every meal.I just didn't know she was a total feeder until today. CNA #14 was also interviewed. CNA #14 stated, She usually feeds herself.some days she won't and then we feed her.if she sits for a couple of minutes and doesn't do anything we feed her. CNA #14 was asked how much Resident #110 usually ate at meals. She stated, She doesn't eat much, but she will drink all of her liquids. This surveyor spoke with RN #1 at approximately 1:00 p.m., at the nurse's station. RN #1 was asked if Resident #110 had consumed all of the liquids on her tray at lunch time. She stated Yes. The care plan was then reviewed. A problem area dated 09/24/2013 was: Resident for potential for alteration in nutritional status due to leaves 25 percent or more of most meals on tray and recieves (sic) theraputic (sic) diet as ordered. Approaches included but were not limited to: Milk X 3, extra ice cream with lunch and dinner meals, monitor and record intake daily, feeds self after set up @ X's (times) does not assist as needed and encourage, carnation instant breakfast shake, 1 packet mixed with whole carton of whole milk and ice cream, lunch, dinner and HS, [MEDICATION NAME] TID (12/3/13), RNP for eating (1/14/14)., med pass 120 cc TID (12/3/13), health shake TID with meals (2/25/14), unavoidable weight loss to be completed by MD/nrsg/RD (2/25/14). Weights recorded on the care plan included: 12/10/13 96 pounds 12/17/13 97 pounds 12/24/13 99 pounds 12/31/13 98 pounds 01/07/14 100 pounds [DATE] pounds [DATE] pounds down 6 pounds 2/25/14 87 pounds 3/4/14 85 pounds 3/11/14 83 pounds The DM (dietary manager) came to the conference room on 03/12/2014 at approximately 1:20 p.m. to speak with this surveyor. The DM was asked about the Unavoidable weight loss form and the documentation regarding Resident #110's refusal of dietary interventions. The DM stated, I would prefer you talk to (name of RD) about what that means, that is her note.I don't want to speculate. The DM was asked about the Super cereal listed in the RD's notes. She stated, We don't need an order for [REDACTED]. On 03/12/2014 at approximately 2:12 p.m., the DON (director of nursing) was interviewed regarding Resident #110's weight loss. The DON stated, We get weights on everyone monthly.the weights are done and go to the ADON, the ADON reviews the weights and determines if the weights are accurate of if she thinks the resident should be reweighed.they have until the fifth of each month to get the weights, do any reweighs and get the weights to me.I put them in the computer.we discuss any weight loss at the QA meetings.I put copies of the monthly weights in both ADON's, the DM, and the administrator's mail box.what should have happened is the weight loss for (Resident #110) should have been picked up on and brought to me before I ever got the list of weights.I should have been told that we had an issue.the print out of weights went out on 2/10 to discuss in QA on 2/11, we didn't pick it up, it fell through the cracks.the RD picked up on it when she looked at the weights and she emailed me that we should put her back on weekly weights, that was on 2/25 and she weighted 87 pounds.it just fell through the cracks, there is plenty of blame to go around on this one. The RD was interviewed via telephone on 03/12/2014 at approximately 3:40 p.m. This surveyor explained to the RD that the survey team had questions regarding her role at the facility and about (Name of Resident #110). The RD stated that she did not have any notes with her regarding Resident #110 but that she would discuss what she could. The RD was asked about her role at the facility. She stated, I am at the facility eight hours per month, I concentrate on the high risk residents when I am there, wt loss, tube feedings and skin breakdowns. The RD was asked if she attended QA meetings at the facility. She stated, No, the DM sits in on the weekly QA meetings and she and the DON relay anything to me that needs to be addressed. The RD was asked how she is made aware of weight losses at the facility. She stated, I get a monthly weight report, it is either emailed to me or is in my mailbox at the facility. The RD was asked about the unavoidable weight loss form that had been completed for Resident #110. The RD was reminded that the form stated Resident #110's weight loss was due tot he resident's refusal to eat and refusal of dietary interventions. The RD was asked what the entry Refusal of dietary interventions meant. She stated, She is refusing to drink her supplements.if you don't eat and you don't take your supplements you are going to lose weight. The RD was asked how she had obtained information that Resident #110 had refused her dietary supplements. She stated, From the staff. The RD was asked if she looked at the MARs for Resident #110 which document her daily supplements. She stated, Sometimes, but I didn't this time. The RD was told that per the MAR and staff interview, Resident#110 takes her supplements every day, each time they are offered. The RD asked if the initials on the MAR indicated the supplements had been given to her to take or did the initials indicate that the supplements had been given to her to take and she actually drank them. The RD was told that per staff interview, the initials indicated that Resident #110 had been given the supplements and she had taken them. If she had not consumed them the initials would have been circled. The RD was then asked if the weight loss would still be considered Unavoidable. She stated, That is a good point, with the information that I had it was unavoidable if she was refusing her supplements.if she is taking her supplements then I would say it is not unavoidable.that really doesn't make sense.I was under the impression that she was not taking them consistently and was consequently losing weight.I guess if she is taking 100 percent of her supplements and continues to lose weight we need to increase her supplements to get more calories in her. The RD was asked why no interventions were implemented with the weight loss of six pounds recorded the first week of February. She stated, Sometimes it is the middle of the month before I get the monthly weights. I don't always get them in a timely manner, sometimes it is the middle of the month and not the beginning of the month when I get them, so they are already a couple of weeks out.that's what happened with her.when I saw the weight loss of six pounds, I emailed the DON and asked for the resident to be put on weekly weights so we could monitor her.then the weight was down more so we added the healthy shake and the doctor added the [MEDICATION NAME] An end of the day meeting was held with the administrator, the DON, and the ADON on 03/12/2014 at approximately 4:40 p.m. The above information was discussed. No further information was obtained prior to the exit conference on 03/12/2014.

Based on observation, staff interview, clinical record review, facility document review, and facility reported incident review, the facility staff failed to ensure safe transfer and provide supervision to prevent injury for two of 16 Residents, Resident #'s 15 and 1. 1. Facility staff failed to follow manufacturers recommendations that one staff move the lifter and the other staff stabilize the resident, and failed to use the proper size lift pad based on the resident's weight. Resident #15 fell and out of the lift and suffered a fractured femur. 2. Resident #1 improperly transferred and suffered a laceration. Findings include: 1. Resident #15 was admitted to the facility on [DATE] with a readmission on 11/03/11, with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly with an assessment reference date of 10/18/13. Resident #15 was assessed as having short and long-term memory loss and severe impairment in daily decision making. A closed record review of Resident #15's clinical record, conducted on 1/15/14, revealed a nursing note dated and timed 12/16/13 1700: "Nurse heard a loud noise coming from 100 hall, ran down and observed resident lying on the floor on her left side, bleeding from her toes on right foot and left knee swelling, CNA (certified nursing assistant) stated she fell off of the hoyer lift pad and landed on the floor, nurse called 911..." A nursing note dated 12/16/13 indicated that the facility was informed by the hospital that Resident #15 had suffered a "left distal fractured femur..." Review of physician order [REDACTED]." Section "G" of the most recent MDS was reviewed and revealed Resident #15 had a score of 4-3 under transfers indicating total assistance with two person physical assist. Resident #15's care plan was also reviewed and revealed (under the heading of) "Resident with mobility deficit" onset date of 7/30/13, "Approaches... Hoyer lift for all transfers with assist times 2 staff..." On 1/15/14 the administrator presented an incident report regarding Resident #15's fall. Hand written witness statements were reviewed from both CNA's involved in the transfer of Resident #15 as follows: "I (CNA's name, CNA #5) was in room (number) helping another CNA (CNA #6) transfer (Resident #15's name) from the bed to the gerichair. After CNA #6 lifted (Resident #15) from the bed with the lift I (CNA #5) began to position the geri chair so that we could sit her in it. I noticed (Resident #15) fall out of the left side of the hoyer pad. I lunged forward to keep (Resident #15) head from hitting the floor while holding (Resident #15) head I began calling for help." Signed and dated 12/16/14. "I (CNA #6) was in room (number) getting (Resident #15) up in her geri-chair with CNA #5. When I was turning the hoyer lift to position the chair under it Resident #15 started falling out of the hoyer pad I then reached out to break Resident #15 fall." Signed and dated 12/16/13. On 1/15/14 at 9:00 a.m. medical record staff (also supply order person) identified as other staff (OS #4) was interviewed regarding observations of new hoyer pads throughout the facility. OS #4 verbalized that the facility had recently been inspecting hoyer pads for wear and tear and replacing as needed. The facility would like to get two pads for each resident incase one was soiled than the other can be used. This surveyor questioned OS #4 regarding proper sizing of hoyer pads. OS #4 explained that pads are sized according to weight and girth of a resident. The hoyer pads are all blue except for the edging which has different colors and that color indicates the size. Residents are sized according to manufacturers recommendations. OS #4 went onto say that as the new hoyer pads arrive the staff are labeling the pads with the Resident's name for easy identification and correct pad. OS #4 was then asked the size of Resident #15's hoyer pad. OS #4 presented a copy of a sizing chart for Resident #15. According to the chart Resident #15 weighed 140 pounds indicating a purple (medium) hoyer pad was to be used. On 1/15/14 at 9:30 a.m. the maintenance supervisor (OS #5) was interviewed regarding inspection of the hoyer lift used to lift Resident #15. OS #5 verbalized the hoyer lift was found to be in good working condition with all mechanics working well. OS #5 verbalized that a pad was attached to the lift but could not recall what size the pad was. On 1/15/14 at 9:35 a.m. the laundry director (OS #6) was interviewed concerning hoyer pads in ill repair. OS #6 verbalized that the laundry department had been observing for any pads coming into the laundry in ill repair. OS #6 then showed this surveyor 3 hoyer pads that had been taken out of service in December due to frayed, worn lift straps, all three hoyer pads had green edging indicating size large. On 1/15/14 at 10:20 a.m. the administrator and director of nursing (DON) were interviewed concerning the transfer of Resident #15. The administrator verbalized that she and the DON were in the facility at the time of the incident and started an investigation of the cause of the incident at that time. According to the administrator the lift and lift pad were in good repair and the cause was unknown stating "it just happened." The administrator did verbalized and showed evidence that the staff were reeducated on proper technique for the use of hoyer lifts. This surveyor then asked to see the hoyer pad used while transferring Resident #15. The administrator verbalized that she was not sure which pad was used but did say it was in good repair and still in circulation and went onto say that the DON also sat in the hoyer sling to test it. This surveyor then asked the DON and administrator to describe the hoyer pad used. Both the DON and administrator described the hoyer pad as being blue with several loops in the pad that help adjust the pad in order to allow a resident to be sat up in a chair or laid down. The DON or the administrator did not describe the color of the outer edge of the hoyer pad to indicate what size the pad was. On 1/15/14 at 10:50 a.m. CNA #5 (witness to the incident) was interviewed via telephone. CNA #5 verbalized that she was assisting CNA #6 transfer Resident #15 to the geri-chair. As CNA #6 controlled the hoyer lift and lifted Resident #15 out of bed, CNA #5 started to move the geri-chair into position, when CNA #5 looked around CNA #6 was turning the hoyer lift and Resident #15 began to come out of the left side of the sling. CNA #5 then ran over to hold Resident #15's head to prevent injury. This surveyor asked CNA #5 how far she was from Resident #15 when Resident #15 was coming out of the sling. CNA #5 verbalized that she was coming around the geri-chair and about two steps away. This surveyor asked CNA #5 to describe the hoyer pad. CNA #5 verbalized that the hoyer pad was blue but could not remember what color the edging of the hoyer pad was. This surveyor asked CNA #5 if Resident #15 was moving about while being transferred. CNA #5 verbalized no, Resident #15 was contracted in her arms and was not moving about. This surveyor asked CNA #5 what could have prevented the fall. CNA #5 verbalized that the sling could have been more custom fit, that the sling was to big and Resident #15 came out of it. On 1/15/14 at 11:50 a.m. CNA #6 (witness to the incident) was interviewed via telephone. CNA #6 was asked the same questions as CNA #5. CNA #6 verbalized that she (CNA #6) had lifted Resident #15 in the hoyer lift and began to turn the hoyer lift, as the hoyer lift was in motion Resident #15 began to slide out of the left side of the hoyer pad and fell to the floor. When asked about the hoyer pad CNA #6 described the pad in good repair, as being blue with green edging (green edging is color coded for being a large pad). CNA #6 also verbalized that she felt the pad was to big for Resident #15. The policy and procedure was reviewed for "Lifting Machine". Under "steps in the procedure" section "I" and "J" it instructs staff to "One assistant is to raise the resident from the bed. The other nursing assistant is to assist the resident in his or her legs off the bed. While nursing assistant #1 moves the lifter, the other nursing assistant is to stabilize the resident movement and provide support." On 1/15/14 at 12:45 p.m. the DON and administrator was informed of the above finding. The administrator verbalized that it was unknown as to what happened. No further information was given concerning the above finding prior to exit conference on 1/15/14. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 1/3/14 coded the resident with a brief interview for mental status (BIMS) score of 15 out of 15 meaning the resident was cognitively intact. The clinical record was reviewed on 1/13/14 and 1/14/14. The nurse's notes documented "1/4/14 1710 (5:10 p.m.) at 1600 (4:00 p.m.) CNAs were transferring resident from w/c (wheelchair) to her recliner. Her leg hit the w/c. She sustained a skin tear to her L (left) lower leg. Bleeding controlled. Area cleaned with NS (normal saline). Patted dry. Steri-strips applied." A physician's recertification visit note on 1/9/14 documented "also pt lacerated L lower leg several days ago. Has a 2" (two inch) laceration. Too late to suture." On 1/14/14 at 10:15 a.m., the resident was interviewed. During the interview, this surveyor asked the resident about her left lower leg and what had occurred. The resident stated "there was one CNA in front of me and one behind me. They were putting me in the chair (pointing to the recliner) from my w/c and they missed and cut my leg on the wheelchair." On 1/14/14 at 11:20 a.m., the administrative team was made aware of the findings during a meeting with the survey team. This surveyor asked to see the investigation for this incident. On 1/14/14 at 2:30 p.m., this surveyor was provided with the investigation. The CNA's written statements both documented that they were positioned with one in the front of the resident and the other behind the resident for the transfer when the incident occurred. The intervention to be put in place to reduce the risk of this occurring again documented "staff educated to monitor surroundings while transferring resident." On 1/14/14 at 4:10 p.m., this surveyor went with licensed practical nurse (LPN) #5 to observe the resident's wound during a dressing change. The resident was again asked about what had occurred on 1/4/14. The resident stated the same statement as the 10:15 a.m. interview. When asked about the bleeding, the resident stated "there was a lot of blood. It was all over my sock too." After the dressing was changed, LPN #5 was asked about the wound. She stated 'this is the first time I saw this area; I am surprised at the size of it." On 1/15/14 at 9:50 a.m., the maintanence director was asked about the resident's wheelchair and if it had been inspected after the 1/4/14 transfer with laceration. The maintanence director stated "I was asked to check the wheelchair. I did not find any sharp areas that the resident would have cut herself on. There was nothing wrong with the wheelchair." On 1/15/14 at 10:15 a.m., the assistant director of nurses (ADON) for the unit who investigated the incident was asked about the way the staff transfered the resident. She stated "the transfer was inappropriate. They should have each been on one side of the resident, not one in front and one in the back." She went on to state "I re-educated them on transfers." This surveyor asked if the ADON had seen the "skin tear" that was documented in the nurses notes. She stated "Yes, the laceration is a large area with depth." She went on to state "the doctor was in to check on the area today for the follow up visit. He said it will take at least three weeks to heal." No other information was provided to this surveyor prior to the exit conference on 1/15/14.