Every finding on record at Fountain Inn Post Acute

Based on observation, interview, record review, and facility policy review, the facility failed to store respiratory equipment appropriately for 2 (Resident (R)5 and R66) of 3 sampled residents reviewed for respiratory care.Findings included: An undated facility policy titled, Storage of Respiratory Equipment, indicated, All respiratory equipment shall be stored in a manner that maintains cleanliness, prevents contamination, ensures readiness for use, and complies with infection prevention and life safety standards. Procedures 1. General Storage Requirements * Respiratory equipment must be stored: * In a clean, dry * Off the floor and away from sinks, toilets, and splash zones * Protected from dust, moisture, and temperature extremes * Storage areas must be clearly labeled and routinely inspected. 1. An admission Record indicated the facility admitted R66 on 12/13/2025. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, mixed simple, and mucopurulent chronic bronchitis. R66's Brief Interview for Mental Status dated 12/15/2025, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The Baseline Care Plan Person-Centered Care Planning, with an effective date of 12/15/2025, revealed interventions and goals to include the resident should have supplemental oxygen at 2 liters by way of a by wat of AVAPS/CPAP every night at bedtime. R66's Order Summary Report, with active orders as 12/17/2025, revealed an order dated 12/14/2025 for average volume-assured pressure support/continuous positive airway pressure (AVAPS/CPAP) every night at bedtime. During an observation on 12/15/2025 at 10:50 AM, R66's face mask for their CPAP was observed lying on the bedside table not in a bag. During an interview on 12/16/2025 at 1:18 PM, R66 stated they brought the CPAP from home and used it every night. R66 stated they did not know if staff ever placed the CPAP mask in a bag. During an interview on 12/17/2025 at 3:03 PM, Licensed Vocational Nurse (LVN)2 stated a resident's CPAP mask should be bagged and labeled with a date. During an interview on 12/16/2025 at 1:25 PM, LVN8 stated CPAP masks should be bagged and the nurses were responsible for bagging the masks. During an interview on 12/18/2025 at 12:16 PM, the Director of Nursing (DON) stated a resident's CPAP mask should be cleaned and bagged. The DON stated she expected a resident's CPAP mask to be in a bag if it was not in use. During an interview on 12/18/2025 at 12:36 PM, the Administrator stated a resident's CPAP mask should typically be stored in a bag when not in use. 2. An admission Record revealed the facility admitted R5 on 11/25/2024. According to the admission Record, the resident had a medical history that included diagnoses of acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and asthma. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident received oxygen therapy. R5's Care Plan Report included a focus area revised 07/17/2025 that indicated the resident was at risk for complications with the respiratory system due to asthma, COPD, chronic respiratory failure, congestive heart failure, dyspnea, and shortness of breath. Interventions directed staff to administer nebulizer treatments as ordered (initiated 12/16/2024). R5's Order Summary Report with active orders as of 12/17/2025, revealed an order dated 12/12/2024, for albuterol sulfate inhalation nebulization solution 2.5 milliliters (ml)/3 ml 0.083%, inhale 3 ml orally every six hours as needed for shortness of breath. During an observation on 12/15/2025 at 12:14 PM and 12/16/2025 at 1:19 PM, R5's nebulizer machine was observed uncovered. at the bedside of the resident. During a concurrent interview and observation on 12/16/2025 at 1:26 PM, LVN4 stated residents' respiratory equipment should be covered when not in use, usually inside of a plastic bag. LVN4 observed R5's nebulizer mask stored in the nebulizer machine's built-in holder and not covered. LVN4 stated R5's nebulizer should have been covered. During an interview on 12/18/2025 at 12:18 PM, the Director of Nursing (DON) stated she would expect a resident's nebulizer mask to be stored in a bag when not in use. The DON stated covering the nebulizer masks would be the responsibility of the nurses. During an interview on 12/18/2025 at 12:37 PM, the Administrator stated he would expect nursing staff to maintain respiratory equipment in accordance with the DON's guidance. During an interview on 12/18/2025 12:47 PM, Registered Nurse (RN)5, who served as the Infection Preventionist, stated she would expect respiratory equipment to be stored in a bag with the resident's name on it.

Based on interview, record review, and facility policy review, the facility failed to implement a comprehensive person-centered care plan to maintain the resident's highest physical well-being for 1 (Resident (R)29) of 3 sampled residents reviewed for falls.Findings included:A facility policy titled, Falls - Clinical Protocol, revised 03/2018, revealed, 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. The policy specified, 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify interventions to try to prevent subsequent falls and to address the risk of clinically significant consequences of falling.An admission Record revealed the facility admitted R29 on 04/15/2025. According to the admission Record, the resident had a medical history that included diagnoses of senile degeneration of the brain, atrial fibrillation, and hypertension. Per the admission Record, R29 discharged from the facility on 11/13/2025.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2025, revealed R29 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS revealed the resident required partial/moderate assistance with rolling left and right in bed and chair/bed-to-chair transfers.R29's Care Plan Report included a focus area initiated 04/17/2025, that indicated the resident was at risk for falls with or without injury related to altered balance while standing and/or walking, altered mental status, antidepressant medication, antihypertensive medication, cardiovascular disease, decreased muscular coordination, history of falls, unsteady gait, and visual impairment. Interventions directed staff to conduct every-one-hour rounding (initiated 05/06/2025).R29's Rehab - Status Post-Fall Screen, electronically signed by Physical Therapist #9 and dated 05/05/2025 at 5:37 PM, revealed that on 05/05/2025 at 12:00 PM, R29 had an unwitnessed fall onto the floor in the resident's room and was found underneath their bed in the resident's room by a certified nursing assistant, with no signs or symptoms of skin bruising, tearing, or discoloration. The Rehab - Status Post-Fall Screen revealed the fall incident was discussed with the Interdisciplinary Team and an intervention for hourly rounds was implemented.During an interview on 12/19/2025 at 10:25 AM, the Director of Nursing stated she was not able to find any documentation in R29's medical record that indicated that one-hour rounding was being conducted in accordance with the resident's care plan.During an interview on 12/19/2025 at 12:02 PM, the Administrator stated he would expect facility staff to follow the resident's care plan.

Based on interview, record review, and facility policy review, the facility failed to provide care and services necessary to maintain or improve the highest practicable physical well-being of a resident receiving dialysis by not following physician-ordered fluid restrictions for 1 (Resident (R)70) of 1 sampled resident reviewed for dialysis.Findings included:A facility policy titled, Encouraging and Restricting Fluids, revised 10/2010, indicated, The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. The policy specified, 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate when recording fluid intake.An admission Record indicated the facility admitted R70 on 10/14/2025. According to the admission Record, the resident had a medical history that included diagnoses of end stage renal disease, hypotension of hemodialysis, and dependence on renal dialysis.A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/03/2025, revealed R70 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received dialysis.R70's Care Plan Report included a focus area initiated 10/15/2025, that indicated the resident required hemodialysis due to a diagnosis of end stage renal failure. Interventions directed the staff to provide a fluid restriction of 360 milliliters (ml) for breakfast, 240 ml for lunch, 240 ml for dinner, 180 ml for the 7:00 AM to 7:00 PM shift, and 180 ml for the 7:00 PM to 7:00 AM shift, for a total of 1200 ml per day.R70's Order Summary Report with active orders as of 12/17/2025, revealed an order dated 10/25/2025 for a fluid restriction of 360 ml for breakfast, 240 ml for lunch, 240 ml for dinner, 180 ml for the 7:00 AM to 7:00 PM shift, and 180 ml for the 7:00 PM to 7:00 AM shift, for a total of 1200 ml per day.R70's medication administration record (MAR) for the timeframe 10/01/2025 - 10/31/2025, revealed the staff recorded the resident received 1080 ml of fluids during the 7:00 AM to 7:00 PM shift on 10/16/2025, 1080 ml of fluids during the 7:00 PM to 7:00 AM shift on 10/16/2025, 700 ml of fluids during the 7:00 AM to 7:00 PM shift on 10/17/2025, 240 ml of fluids during the 7:00 PM to 7:00 AM shift on 10/17/2025, 360 ml of fluids during the 7:00 AM to 7:00 PM shift on 10/21/2025, 840 ml of fluids during the 7:00 AM to 7:00 PM shift on 10/30/2025, and 840 ml of fluids during the 7:00 PM to 7:00 AM shift on 10/30/2025.R70's MAR for the timeframe 11/01/2025 - 11/30/2025, revealed evidence to indicate the resident exceeded the ordered 180 ml of fluids during the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM shift on 11/03/2025, 11/04/2025, 11/06/2025, 11/07/2025, 11/08/2025, 11/10/2025, 11/13/2025, 11/17/2025, and 11/20/2025 - 11/30/2025.R70's MAR for the timeframe 12/01/2025 - 12/31/2025, revealed evidence to indicate the resident exceeded the ordered 180 ml of fluids during the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM shift on 12/02/2025 - 12/04/2025, 12/06/2025, 12/07/2025, 12/09/2025, and 12/11/2025 - 12/17/2025.During an interview on 12/19/2025 at 8:12 AM, Licensed Vocational Nurse (LVN)6 confirmed R70 was on fluid restriction, which meant there was a limit on the amount of fluids the resident could receive.During an interview on 12/19/2025 at 8:45 AM, LVN2 stated R70 should not be given more than 1,200 ml of fluids per day.During an interview on 12/19/2025 at 9:42 AM, the Director of Nursing stated staff should monitor a resident's fluid intake if the resident had an order for a fluid restriction.During an interview on 12/19/2025 at 9:55 AM, the Administrator stated staff should adhere to a resident's fluid restriction.

Based on observation, interview, and facility policy review, the facility failed to ensure appropriate storage and disposal of drugs and biologicals during observation of medication administration with 1 (Resident (R)74) of 5 residents observed for medication administration.Findings included:A facility policy titled, Storage and Expiration Dating of Medications and Biologicals, revised 06/30/2025, revealed, 5. Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.A facility policy titled, Disposal of Medications, revised 08/26/2025, revealed, 13.2 Wasted single doses of medications for disposal should [be] disposed of in a manner that limits access to them by unauthorized personnel or residents.During medication administration observation on 12/17/2025 at 9:24 AM, Licensed Vocational Nurse (LVN)2 prepared medication to be administered to R74. LVN2 dropped one multivitamin with minerals capsule and placed the capsule into the medication cart trash can.During an interview on 12/17/2025 at 9:50 AM, LVN2 stated he did not realize he disposed of a multivitamin with minerals capsule in the medication cart trash can. LVN2 stated medication should be disposed of in the medication cart sharps container.During an interview on 12/17/2025 at 10:57 AM, the Director of Nursing stated she would expect wasted medications to be disposed of in a sharps container or in a drug disposal solution and not in a regular trash can.During an interview on 12/18/2025 at 12:39 PM, the Administrator stated he would expect nursing staff to dispose of medications in a sharps container or something that was biosafe.

Based on review of the facility policy, observation and interview, the facility failed to ensure medications were free of expiration and properly labled for 2 of 3 medication carts and 1 of 1 treatment carts. Findings include: Review of the facility policy dated 2001, titled, Medication Labeling and Storage, revealed under the policy, If the facility has discontinued , outdated or deteriorated medications or biologicals, the dispending pharmacy is contacted for instructions regarding returning or destroying these items. Labeling of medications and biolagicals dispensed by the pharmacy is consistant with applicable federal and state requirements and currently accepted pharmceutical practices. The medication label includes, at a minimum: medication name, prescribed dose, strength, expiration date, when applicable, residents name, route of administration and appropriate instructions and precautions. An observation of the treatment cart on [DATE] at 9:41 AM revealed the following: Nystation cream for Resident (R) 47 with a label for 7 days, dated [DATE]. There was no lot number. Mupirocin 2% with a label for R27 to apply to left lower leg; one time day for skin infection until [DATE]- Lot #291044. Greers [NAME] with an open date of [DATE], and expiration date of [DATE], Lot number 1988939.02. Minerin Cre'me- discard date of [DATE], Lot # 62647981. On [DATE] at 10:03 AM, an interview with Licensed Practical Nurse (LPN)3 revealed, The medications were expired and should have been discarded. LPN3 then stated, I usually go through the carts once a week, and the nurses also go through them. An observation of Medication 300 Cart, on [DATE] at 3:41 PM with LPN2 revealed the following; A bottle of Oyster Shell Calcium 500 milligram (mg) stock with expiration date of ,d+[DATE]. Lot # none. EV0822BA number was on the label. Levemir Flex Pen, Lot # 4F9602A Date open [DATE], discard after 28 days. LPN2 confirmed today was day 30. Even Care G3 Test Strips Glucose Control, not dated with open date. Lot# ,d+[DATE]. Refresh Tears opened, not dated. room [ROOM NUMBER] B. Geri Care Iron Supplement, with date rubbed off. LPN2 could not identify the date, this writer cannot identify the date and the lot number was also rubbed off. An observation of medication cart 200 with LPN1 on [DATE] at 4:05 PM revealed the following; Tresiba Flex Touch Pen Insulin Degludec- no open date or expiration date. Discard after 28 days. LPN1 said she will look it up to see when it was ordered. Insulin Lispro kwik Pen open date [DATE]. Date expired [DATE]. Discard after 28 days. Lot#D707988A Novolin Lot # PZFAG68, opened, discard date after 28 days. There was no open date or expiration date. Liquid Protein 30 fluid Ounces, Lot# X1050124 . About ,d+[DATE] remains in the bottle. There was no open date. LPN1 confirmed the medications were either not dated or expired. On [DATE] at 1:11 PM, an interview with the Director of Nurses (DON) revealed, The unit managers (UM) are supposed to complete weekly audits on the medication carts. The nurses are ultimately responsible for their cart, checking dates and discarding expired items or discontinued medications. The UM are to keep the treatment carts clean, discard if out of date, or if anyone has been discharged or passed.

Based on observation, interview, and facility policy the facility failed to offer/provide Activities of Daily Living (ADL) care to Resident (R)12 and R27. 2 of 3 reviewed for ADL care. Findings include: Review of facility policy titled, ADLs Supporting revealed Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive necessary services to maintain good nutrition, grooming, personal, and oral hygiene. Policy interpretation and implementation include residents will be provided with care, treatment, and services to ensure that ADL do not diminish unless the circumstances of their clinical condition (s) demonstrate that diminishing ADLs are unavoidable. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. R12 was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease, legal blindness, mental disorder, and major depressive disorder. Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/24, revealed R12 has a Brief Interview of Mental Status (BIMS) score of 03 out of 15, which indicates that she is not cognitively intact. Further review of the Quarterly MDS revealed R12 is dependent on staff for shower/bathing and personal hygiene. An observation on 09/24/24 at 9:30 AM revealed R12 in bed in her night wear, in need of facial care, oral care, and dry hair with dandruff build-up. A second observation on 09/25/24 at 8:02 AM revealed R12 in bed in her night wear, with dry hair and dandruff build-up. An observation and interview on 09/25/24 at 8:06 AM with Licensed Practical Nurse (LPN)5 revealed that the resident is legally blind, but if staff introduce themselves appropriately prior to giving her care that the resident is more agreeable to ADL care. LPN5 further stated that the resident has an order for Anti-Dandruff External Shampoo 1 % (Selenium Sulfide) that is to be applied by the Certified Nursing Assistants (CNA) on the resident's shower days. LPN5 observed R12's hair and agreed the resident has dandruff in her hair. Record review on 09/25/24 at 8:30 AM of R12's Physician Orders for September 2024 revealed that R12 has an order for Anti-Dandruff External Shampoo 1 % (Selenium Sulfide) to be applied on shower days (Tuesday, Thursday, Saturday). Record review on 09/25/24 at 8:33 AM of the Paper CNA Shower Sheet for the 300 Unit for the period 08/24/24-09/24/24 revealed no CNA Shower Sheet documentation for R12. Record review on 09/25/24 at 8:34 AM of the Electronic Medical Record (EMR) Bathing ADL Documentation for the period 08/27/24 - 09/24/24 revealed 1 shower for R12 on 09/19/24 and was completed at 10:11 PM. Further review of R12's ADL documentation revealed that R12 received bed baths on 08/30/24, 08/31/24, 09/3/24, 09/11/24, 09/13/24, 09/14/24, and 09/17/24. Record review on 09/25/24 at 8:37 AM of R12's Nurses Notes revealed no documentation of refusal of ADL care during the period of 08/27/24 - 09/24/24. Record review on 09/25/24 at 8:40 AM of R12's Care Plan, last revised 07/07/24, revealed Resident needs assistance with ADLs related to legal blindness, debility, and protein calorie malnutrition. Interventions include assist with AM and PM care as needed, bed mobility assist with one person, dressing with one assist. An interview with the Director of Nursing (DON) on 09/25/24 at 12:34 PM revealed that she expects residents to be offered/provided a shower at least twice a week and be offered/provided a bed bath every day other than shower days. The DON further stated that she expects for staff to document when residents refuse ADL care. R27 was admitted to the facility on [DATE] with diagnoses including but not limited to; vascular dementia without behaviors, congestive heart failure, and major depressive disorder. Review of the Annual MDS with an ARD date of 08/06/24 revealed R27 has a BIMS score of 14 out of 15, which indicates that he is cognitively intact. Further review of the annual MDS revealed R27 requires set up or clean up assistance with personal hygiene and partial/moderate assistance with shower and bathing. An observation and interview on 09/22/24 at 1:27 PM revealed R27 in bed without a shirt and with body odor. R27 stated that he prefers to stay in bed without a shirt most days. An observation on 09/24/24 at 8:20 AM revealed R27 in bed without a shirt on, eating snacks with a body odor still present. Record review on 09/24/24 at 09:10 AM of R27's ADL Documentation for the last 30 days (08/26/24 - 09/24/24) revealed Type of Bath and R27 received bed baths on the following dates - 08/31/24, 09/04/24, 09/14/24, and 09/24/24). There was no documentation of the resident receiving a shower during this period. Record review on 09/24/24 at 09:23 AM of R27's ADL Documentation for the last 30 day (08/26/24 - 09/24/24) Comments revealed on 09/24/24 at 02:23 AM and 02:25 PM, R27 He needs a good shower asap. An interview on 09/24/24 at 9:30 AM with CNA1 revealed that the resident receives showers on Wednesday's and Saturday's but often refuses. On the days in between the resident's shower days, he receives bed baths when he allows staff to provide care. CNA1 further stated that when residents refuse, they will offer 3 times and inform the nursing staff. ADL refusals are to be documented in the Electronic Medical Record (EMR) by both CNAs and Nursing Staff. A phone interview on 09/24/24 with CNA2 revealed they wrote in the ADL Documentation that R27 needs a good shower due to his body odor. CNA2 stated that showers are provided during the day shift, but they provided R27 a bed bath last night (09/23/24) after he had a bowel movement. CNA2 stated that R27 can be resistive to care, but they are able to redirect the resident after a few attempts, and eventually he is agreeable to ADL care. An interview with the Director of Nursing (DON) on 09/24/24 at 5:05 PM revealed the 300 Unit Shower Documentation Sheets and that staff are required to document on the shower sheets and in the medical record when showers/bed baths are completed. Review of the shower documentation sheets revealed one shower/bed bath during the period 08/24/24 - 09/24/24 dated 09/04/24, resident received a bed bath on that date. An observation and interview on 09/25/24 at 8:06 AM with LPN5 revealed that the resident can be resistive to ADL care and specifically receiving showers at times. LPN5 further stated that the CNAs are responsible for ensuring residents receive ADL care and if a resident refuses they should inform the nurse of the situation so they can document the refusal in the resident's EMR. During an observation, this surveyor and LPN5 spoke with resident, and exited room. LPN5 stated that R27 did have body odor and would follow up with his CNA for the day related to his ADL care and shower schedule. Record review of R27's Care Plan, last revised 08/11/24, revealed R27 requires assistance with ADLs related to congestive heart failure, vascular dementia, and major depressive disorder. Interventions include assist resident with bathing with one assist, resident has history of refusal of baths, incontinent care, and getting out of bed. Record review of R27's Nurses Notes for September 2024 revealed no documentation of refusal of ADL care.

Based on review of the facility policy, observation, record review and interview, the facility failed to ensure the medication error rate was 5% or less. The medication error rate was 7.69%. Findings include: Review of the facility policy, dated 2001 and titled, Administering Medications records under the policy, Medications are administered in accordance with prescriber orders, including any required time frame. An observation was conducted on 09/23/24 at 9:17 AM of Licensed Practical Nurse (LPN)1 during medication administration for Resident (R)4. During medication administration LPN1 stated, There are 2 medications that I do not have available to give him right now. I will make the Unit Manager (UM) and Nurse Practitioner (NP) aware. The medications that were not available included Floraster oral capsules and Donepezil 10 milligrams (mg). Record review for R4 revealed he was admitted to the facility on [DATE] with diagnoses to include the following; acute respiratory failure with hypoxia, Type 2 diabetes, morbid obesity, sick sinus syndrome, atrial fibrillation, chronic kidney disease and hypertension. Record review of R4's physician orders revealed Floraster Oral Capsule- give 1 capsule by mouth two times a day, order date 08/18/24 and Donepezil Tablet 10 mg- 1 tablet by mouth one time a day, order date 08/19/24. Record review of R4's medication administration record (MAR) revealed on 09/23/24, LPN1 signed the Florastor at 0900 and Donepezil 0900 medication with a code of 9, which indicated other, see nurses notes. On 09/24/24 at 10:27 AM, during an interview with LPN1, she stated, I called the pharmacy yesterday to have the 2 medications delivered for R4. I also told my UM and the NP. There was not an order to hold the medication for 1 day or until the medication arrived from pharmacy, I looked for it. I didn't document it in the nurses notes. On 09/25/24 at 11:54 AM, during an interview with the Director of Nurses (DON), she stated, For medications not available, contact the physician (MD) or NP, tell them, usually they will order for the medications to be placed on hold. Then notify the residents representative and resident that the medication is not available. Once it comes in, then notify MD to release the hold. The DON confirmed LPN1 did not follow these steps.

Based on interview, record review, and review of the facility policy, the facility failed to accurately submit the Payroll Based Journal (PBJ) for Quarter Three (April 1st - June 1st), 2024 to reflect Registered Nurse (RN) hours. 15 of 19 days reviewed for RN coverage. Findings include: Review of facility policy titled, Reporting Direct Care Staffing Information (PBJ) last revised August 2022, revealed Direct care staffing is reported electronically to CMS through the PBJ System. Policy Interpretation and Implementation include complete and accurate direct care staffing information is reported electronically to CMS through the PBJ system in a uniform format specified by CMS. Direct care staff are those who, through interpersonal contact with residents or resident care management provide care and services to allow residents to attain or maintain their highest practicable physical, mental, and psychosocial well being. Record review prior to the entrance of the survey of the PBJ Staffing Data Report for Quarter 3 (April 2024 - June 2024) revealed the following dates with missing RN Coverage: 05/02/24; 05/15/24; 05/20/24; 05/22/24; 05/23/24; 05/29/24; 06/03/24; 06/05/24; 06/10/24; 06/12/24; 06/17/24; 06/19/24; 06/24/24; 06/26/24; 06/27/24. A phone interview on 09/22/24 at 2:13 PM with the Administrator revealed that the previous staff member that was responsible for submitting the PBJ Staffing submitted the data incorrectly by failing to include RN hours in the staffing report. Record review on 09/25/24 at 12:01 PM for May 2024, June 2024, July 2024, August 2024, and September 2024 revealed the facility did have adequate RN coverage. The facility is a 60 bed facility and utilized the Director of Nursing (DON) as their RN coverage most week days. A follow up phone interview with the Administrator on 09/25/24 at 12:45 PM revealed that the facility had an error with submitting the PBJ data related to the unit managers and the DON being salary employees. The previous person that was submitting the PBJ did not include their hours, which made the facility reflect not having RN hours.

Based on interview, facility policy, and federal regulation the facility failed to provide documentation that the Medical Director (MD) attended the quarterly Quality Assurance and Performance Improvement (QAPI) Program. 1 of 2 Quarters reviewed. Findings include: Review of facility policy titled, QAPI Program revealed This facility shall develop, implement and maintain an ongoing, facility wide, data driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy interpretation and implementation include the Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state and local regulatory agency requirements. A phone interview on 09/25/24 at 12:45 PM with the Administrator revealed that have recently been hired at the facility, during interview the Administrator revealed he was unable to find sign in sheets to verify that the previous Medical Director (MD) attended the quarterly QAPI meetings. An interview on 09/25/24 at 1:39 PM with the current MD for the facility revealed that they attended QAPI meeting in July, but a sign in sheet was not available.

Based on review of the facility policy, observation, and interviews, the facility failed to follow proper infection control practices to clean the glucometer for 1 of 1 resident (R) reviewed for glucometer cleaning. Findings include: Review of the facility's policy dated 05/25/2019, and titled, Glucometer Cleaning revealed The purpose of this procedure are to provide guidelines for cleaning a glucometer used for blood sugars and to prevent the introduction of bacteria. If residents use individual glcometers, clean prior to use or when visibly soiled. On 09/24/2024 at 8:19 AM, an observation of Registered Nurse (RN)1 performing an accu check revealed the following: RN1 stated, All the glucometers are individual. She then removed the glucometer from the medication cart. She was asked if she cleaned the glucometer, RN1 said, No, it should be clean since it was in the container for the resident. She placed a barrier on an overbed table and placed the glucometer on the barrier. RN1 donned gloves, cleaned the finger with an alcohol prep pad, and pricked it with a lancet. After obtaining the blood glucose reading, RN1 exited the room without handwashing or sanitizing, placed the accu check machine back into the container, without cleaning it, and placed into the medication cart. She then went back to the room to wash her hands. On 09/24/2024 at 8:40 AM, an interview with RN1 revealed, The blood glucometer should still be cleaned after each use. I'll go back and clean it. On 09/24/2024 at 2:00 PM, an interview with the Director of Nurses (DON) revealed, If residents use individual glucometers, clean prior to use or when visibly soiled. On 09/24/2024 at 2:50 PM, a second interview with the DON revealed, I was incorrect, we clean the glucometers after use, not before.

Based on review of facility policy, observations, and interviews, the facility failed to ensure staff performed adequate hand hygiene for three of three survey days. Failure to perform adequate hand hygiene can lead to cross contamination. Findings include: Review of the facility's policy titled, Hand Hygiene Policy and Table, dated 05/20/19, revealed, Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Between resident contacts . [and] after handling contaminated objects . The use of gloves does not replace hand hygiene if your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Observation on 07/25/22 at 1:15 PM revealed Certified Nursing Assistant (CNA)3 already in room feeding resident (R) 35 with gloves on. After feeding R35, CNA3 took off her gloves and left R35's room briefly to talk with someone in the hallway. CNA3 was not observed performing hand hygiene before returning to R35's room. CNA3 wiped R35's mouth with a washcloth and packed up the food tray. When asked if she performed hand hygiene after taking off her gloves and before returning to the room, CNA3 stated, No. Observation during medication administration on 07/26/22 at 8:56 AM revealed Registered Nurse (RN)1 donned gloves before pulling a medication. RN1 did not perform hand hygiene before donning the gloves. Further observation on 07/26/22 at 11:40 AM during medication administration with RN1, RN1 donned a pair of gloves before pulling a medication and doffed the gloves thereafter. RN1 did not perform hand hygiene before donning and after doffing the gloves. RN1 then placed medications and a pair of gloves on a tray and proceeded to R38's room. RN1 touched the curtains in the room with bare hands and performed no hand hygiene before donning gloves to administer medications to R38. RN1 returned to medication cart, picked up a pen and documented on the cart. RN1 still performed no hand hygiene. On 07/26/22 at 11:48 AM, RN1 donned gloves to pull more medications without performing hand hygiene. RN1 performed hand hygiene at 11:56 AM for the first time since observation began at 11:40 AM. In an interview with RN1 at 11:56 AM, RN1 was told that she had been observed not performing hand hygiene between several glove changes and that she did not have hand sanitizer on her cart. RN1 stated that she could use the sanitizer on the wall and that she had hand sanitizer in her pocket. She pulled a small bottle of sanitizer from her pocket. RN1 admitted that she had not used either source of sanitizer between several glove changes. Observation on 07/27/22 at 8:21 AM, during medication administration, revealed RN2 donning gloves without first performing hand hygiene. RN2 removed the gloves and picked up the water pitcher on the cart, poured some water in a cup and then performed hand hygiene. On 07/27/22 at 8:35 AM, RN2 accidentally dropped a pill. RN2 located the pill on the floor behind the medication cart and picked it up with bare hands. RN2 did not perform hand hygiene before proceeding to R47's room to check R47's blood pressure. Interview with the Administrator on 07/27/22 at 11:39 AM revealed that her expectation was that staff should adhere to the facility's hand hygiene policy. The Administrator confirmed that the facility's handwashing policy required hand hygiene before donning gloves and immediately after undonning gloves. Interview on 07/27/22 at 2:55 PM with the Assistant Director of Nursing/Infection Preventionist (ADON/ICP) revealed that her expectation was that staff perform hand hygiene before entering a resident's room, before and after putting on gloves, and after rest room use. She further confirmed that hand hygiene should be performed immediately after taking off gloves. On 07/25/22 at 12:25 PM, the Speech and Language Pathologist (SLP) was observed in the 300-hall dining room assisting R20 to eat while sitting at the table between R20 and R45. The SLP was using her right hand to assist R20 to eat using the resident's fork. The SLP then picked up a cracker off R45's plate with her bare right hand and put the cracker in R45's mouth. She had not performed hand hygiene before picking up the cracker. The SLP then continued to assist R20 to eat using her right hand without any hand hygiene performed. The SLP then picked up R45's fork with her right hand and assisted the resident to eat a bite without performing hand hygiene. The SLP then used her right hand to touch her bangs and forehead, then used her right hand to feed R20 another bite of food without performing hand hygiene. The SLP was unavailable for interview the remainder of the survey. On 07/27/22 at 2:55 PM, interview with the ADON/ICP revealed staff were expected to perform hand hygiene, either hand washing if the hands were visibly soiled or using hand sanitizing gel, between assisting different residents to eat or after touching their hair or face. The IP stated the dining room had recently been re-opened after a closure due to COVID-19, and she knew the staff would need some reminders on protocols in the dining room. The IP stated training would be done on hand hygiene in the dining room for all staff.

Based on interview and record review, the facility failed to a resident's representative of an abuse allegation involving the resident for 1 of 4 residents reviewed for abuse. Resident (R)1 was involved in a staff-resident abuse allegation but the facility failed to notify family of the incident, investigation, or results of that investigation. The findings included: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility investigation for 11/28/21 incident of verbal abuse on 2/7/22 at approximately 12 PM revealed the facility investigated an incident of verbal abuse involving R1. A nurse alleged that a nurse aide verbally abused the resident. Interview with son of R1 on 2/7/22 at approximately 2:50 PM revealed he was unaware of the abuse allegation involving R1 in November. He confirmed he was the resident representative for R1. Interview with Director of Nursing (DON) and Administrator on 2/7/22 at approximately 3:10 PM revealed there was no documentation that the representative for R1 had been notified of the abuse incident involving R1, the following investigation, or the investigation results. Review of Notification of Changes Policy on 2/7/22 at approximately 3:20 PM revealed that the facility must inform the resident and / or notify the resident's family member or legal representative when there is a change requiring such notification.

Based on observations, staff interviews and review of facility policy, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed. The facility also failed to ensure foods are held and used by date of expiration for 1 of 1 nursing units observed. The findings included: On [DATE] at 11:15 AM, the brief initial tour with Dietary Aide revealed: (1). Two (2) blocks of sliced American cheese and one (1) block of sliced Swiss cheese were in the walk-in refrigerator not properly covered or labeled. (2). One (1) slab of ribs, a zip lock bag of pork chop patties, and a block of ham loosely wrapped in the walk-in freezer not properly covered or labeled. (3). A bag of hamburger buns not properly covered or labeled. (4). Black mold-like substance on the walls behind the dishwasher and the baseboards surrounding the three-compartment sink An interview with the Dietary Aide at 11:25 AM confirmed the sliced American cheese, sliced Swiss cheese, slab of rib, pork chop patties, block of ham, and the hamburger buns were stored without a date or label the items were opened. An interview with the Administrator at 11:47 AM confirmed the black mold substance on the walls behind the dish washer and baseboards surrounding the three-compartment sink. At 12:35 PM, a random observation of the nursing unit revealed: (1). Four (4) bags of Lays classic potato chips with a use by date of [DATE]. An interview with Registered Nurse #1 confirmed the chips had expired on [DATE]. On [DATE] at 3:00 PM, a follow up visit with the Dietary Manager revealed: (1). Black mold like substance on the walls behind the dishwasher and the baseboards surrounding the three-compartment sink. An interview with the Dietary Manager at 3:17 PM confirmed the black mold substance on the walls behind the dish washer and baseboards surround the three-compartment sink. A review of the facility's policy titled Food Safety- Manual Pot and Pan Washing stated, 8. The pot and pan area (including the floor and walls) should be completely cleaned and sanitized after the procedure has been completed. Also, the facility's policy on Dietary Department Infection Control stated, Food is purchased, prepared, stored, transported and served in ways that minimize contamination by microorganisms and dangerous chemicals.

Based on observations, record reviews and interviews, the facility failed to adhere to Care Plan Interventions by not monitoring Side Effects and Mood/Behavior daily for [MEDICAL CONDITION] drug use for 1 out of 5 residents charts reviewed for unnecessary medications. Findings include: On 1/26/21 at approximately 2:35 p.m., a review of Care Plan for resident # 3 revealed that interventions were in place to observe resident for side effects and mood and behavior status and record behaviors as applicable, notify physician as needed. Medication Administration Records revealed that resident # 3 is currently receiving [MEDICATION NAME] 5 mg daily for depression and [MEDICATION NAME] 7.5mg at bedtime Appetite stimulant/Anti-depressant. Medication Administration Record [REDACTED]. An interview on 1/27/20 at 2:25 p.m. with the Director of Nursing states that the physicians order for monitoring of [MEDICAL CONDITION] drugs is usually transferred over on the Medication Administration Record, [REDACTED]. The DON stated the corrections have been made, the staff has been educated, and all medical records will be assessed to ensure all residents on [MEDICAL CONDITION] drugs are being monitored.

Based on observation, interview, review of facility policy, and manufacturer ' s instructions, the facility failed to provide sanitary insulin administration during 1 of 1 insulin injections observed during the survey. The nurse failed to clean the [MEDICATION NAME] rubber seal prior to insulin administration to Resident #28. The findings include: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/27/2021 at 11:30 AM, Registered Nurse (RN) # 2 was observed preparing insulin via [MEDICATION NAME] for administration. RN #2 removed the [MEDICATION NAME], the pen needle, and 2 alcohol pads from the medication cart and proceeded to the room of resident #28. RN #2 removed the pen cap and cleaned the site on resident #28 ' s left abdomen in preparation for injection. RN #2 then attached the pen needle to the rubber seal of the [MEDICATION NAME] and administered the medication to the resident ' s left abdomen. RN #2 did not clean the rubber seal with alcohol prior to administering the injection. In an interview with RN #2 on 01/27/2021 at 11:46 AM, RN # 2 confirmed she/he failed to clean the rubber seal with alcohol before attaching the pen needle and stated I forgot and even took 2 alcohol swabs in. Review of the facility ' s policy and procedure for the use of Insulin Pen, Date Reviewed/Revised 10-20-20 revealed the procedure for use of insulin pens, 11. Procedure: . g. Attach safety pen needle: i. Remove the pen cap from the insulin pen. ii. Wipe the rubber seal with an alcohol pad. iii. Twist open and remove outer cover from the safety pen needle. iv. Screw the pen safety needle onto the insulin pen. Review of the [MEDICATION NAME] Manufacturer ' s instructions revealed prior to attaching the needle, Prepare your pen Remove the cap Pull off the pen cap and wipe the rubber [MEDICATION NAME] with an alcohol swab.

Based on observation, interviews and record review, the facility failed to disinfect meal delivery carts with an EPA-registered (Environmental Protection Agency) disinfectant after meal services. There were five meal delivery carts. This deficient practice occurred during the COVID-19 pandemic. The findings included: During an observation on 06/17/2020 at 1:55 PM, two meal delivery carts were observed by the kitchen entry door, with used meal trays from the lunch meal service. During an interview on 06/15/2020 at 1:00 PM, the Certified Dietary Manager was asked about the current practices for cleaning and disinfecting the meal delivery carts. S/he stated the dietary staff don personal protective equipment and remove the dirty trays from the carts. They then clean the carts with an Ecolab cleaner. S/he did not know the cleaning agent that was currently being utilized. The type of cleaning agent and manufacturer's specifics were requested. A review of the Ecolab Safety Data Sheet indicated the product was Oasis 146 Multi-Quat Sanitizer, which contained n-alkyl [MEDICATION NAME] ammonium chloride 3%, Octyl decyl [MEDICATION NAME] ammonium chloride 2.25%, [MEDICATION NAME] 1-5%, Didecyl [MEDICATION NAME] Ammonium Chloride 1.35% and [MEDICATION NAME] ammonium chloride 0.9%. This was the concentration as sold, and undiluted. During an interview on 06/17/2020 at 3:15 PM, the Administrator verified they use Ecolab Oasis 146 Multi-Quat Sanitizer for cleaning the meal carts when they are returned to the kitchen from meal service. Upon request, she reviewed the EPA website, and stated the Oasis 146 was not a cleaner that was on the EPA-registered list as effective against COVID-19. S/he further stated they would only switch to the different cleaner if they had COVID-19 positive residents in the facility. However, during the survey it was observed that other cleaners in the facility had already been changed to EPA-registered disinfectants effective to kill COVID-19, such as the agents being used by housekeeping. The Administrator indicated there were 9 residents who were on a 14-day quarantine, who had been exposed to an employee who tested positive for COVID-19. These residents were receiving normal dinnerware, and not served on paper products. Their meal trays would have been taken from their room and placed back on the meal delivery carts. During an interview on 06/17/2020 at 3:55 PM, Dietary Staff #1 was asked about the process for cleaning the meal delivery carts after meal services. S/he stated the carts were brought into the dishwashing area and s/he would apply a face shield, apron and gloves. S/he would spray down the carts with water, then spray the carts with the Oasis 146 sanitizer. During an interview on 06/17/2020 at 4:00 PM, the Administrator, in the presence of the CDM, stated their policy was to first wash the carts with soap and water, then spray them with Oasis 146. During an interview on 06/17/2020 at 3:45 PM, the facility's Ecolab representative indicated the Oasis 146 was a sanitizer and not a disinfectant. S/he stated a sanitizer and a disinfectant were not the same, and only a disinfectant would be effective to kill COVID-19. S/he indicated some of his other long-term care clients had already made the switch to a disinfectant to clean the meal delivery carts. A review of the Centers for Disease Control (CDC) guidelines titled, Preparing for COVID-19 in Nursing Homes, last updated 05/19/2020, indicated, Environmental Cleaning and Disinfection: - Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; - Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. - Use an EPA-registered disinfectant from List N on the EPA website to disinfect surfaces that might be contaminated with [DIAGNOSES REDACTED]-CoV-2 (COVID-19). Ensure HCP (health care personnel) are appropriately trained on its use.

Based on observation, interview, and record review it was determined the facility failed to ensure one (Resident(R) 20) of 17 sampled residents received adequate supervision to prevent falls. R20 fell 23 times between 9/17/18 and 5/10/19 without injury. Findings include: Review of R20's Face Sheet, located in his/her clinical record, indicated s/he was admitted to the facility on [DATE]. Review of R20's History and Physical (H&P), dated 09/17/18, documented his/her [DIAGNOSES REDACTED]. Review of R20's care plan, dated 09/09/18, documented that R20 was at risk of a fall related injury. Approaches included remind the resident to lock his/her wheelchair brakes before transferring, sit on the edge of his/her bed for a few minutes before rising, transferring with one-person assistance, and to educate and remind the resident to request assistance. Review of R20's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/13/18, documented a Brief Interview of Mental Status (BIMS) score was 08, indicating moderate cognitive impairment. Further review of the MDS indicated the resident required limited assistance from two or more persons for transfers, ambulation in his/her room or the corridor, dressing, and toilet use. The resident was not steady and required human assistance to move from a seated position to standing, walking, turning, moving on and off the toilet, and surface to surface transfers. The MDS also documented the resident had not fallen in the six months prior to his/her admission, nor had s/he fallen since her admission. The quarterly MDS with an ARD date of 03/03/19 revealed the resident had greater than two falls since last assessment with no major injury. Review of a Resident Incident Report (RIR), dated 09/17/18 at 7:46 PM, documented the resident fell in his/her room and was found sitting on the floor with his/her back against the bed. The report documented an impact mat was added to the floor beside the resident's bed, and an updated approach was added to the care plan. Review of a RIR, dated 09/28/18 at 12:15 PM, documented the resident fell in his/her room on the way to the bathroom. A hand-written note on the form documented resident would be toileted while s/he was awake, and his/her care plan was revised to add toileting every 2 hours. Review of a RIR dated 09/30/18 at 4:31 PM, documented resident was found on the floor in his/her room in front of his/her Geri-chair. A hand-written note on the form documented the resident was re-educated to use his/her call light. Review of a RIR dated 10/6/18 at 7:00 AM, documented resident fell trying to get to the bathroom. A hand-written note on the form documented the resident had last been toileted at 7:00 AM and would be moved to a room closer to the nurse's station. Review of a RIR dated 10/12/18 at 4:37 AM, documented the resident had been up and down in his/her room throughout the night with unsafe walking and fell to the floor. A hand-written note on the form documented the resident received hip protectors. Review of a RIR dated 10/14/18 at 9:45 AM, documented resident fell in his/her room, and told the staff s/he had been trying to get his/her pictures down. A hand-written note on the form documented the resident's physician would evaluate and adjust his/her medications. Review of a RIR dated 10/24/18 at 12:15 PM, documented resident was found on the floor in her room, stating s/he had been on the phone, stepped backwards and fell . A hand-written note on the form documented the resident was evaluated for injury and neuro checks were started. His/her care plan documented the MD had reviewed the resident's medications for possible adverse reactions. Review of a RIR dated 10/28/18 at 4:00 AM, documented resident was found sitting on the floormat beside his/her bed, stating that s/he had been trying to get to the bathroom. A hand-written note on the form documented the plan was to continue to toilet the resident every two hours and provide safety education. Review of a RIR dated 10/31/18 at 8:31 PM, documented resident was found on the floor mat next to the bed, and told staff s/he was getting into bed. A hand-written note on the form documented staff were to assist the resident to bed when s/he was fatigued. Review of a RIR dated 11/3/18 at 12:15 AM, documented the resident was laying on the floor at the end of his/her bed, with a tennis ball sized hematoma to his/her forehead. A hand-written note on the form documented the facility placed pool noodles along the edges of the resident's bed to define the parameters of the bed. Review of a RIR dated 11/3/18 at 9:30 PM, documented the resident stood from his/her wheelchair in a common area and tried to walk. A nearby Certified Nursing Assistant (CNA) attempted to get the resident to sit back down, and the resident swung at the CNA and fell . A hand-written note on the form documented a urinalysis was completed on the resident to rule out a Urinary Tract Infection [MEDICAL CONDITION]. The test result was negative for UTI. Review of a RIR dated 11/15/18 at 6:15 AM, documented the resident was found sitting on his/her impact mat beside his/her bed. A hand-written note on the form documented the resident's bed was placed in the low position. Review of a RIR dated 12/4/18 at 11:15 PM, documented the resident was found on the floor of another resident's room on another unit. A hand-written note on the form documented the facility completed a urinalysis to rule out a UTI. The test result was negative for UTI. Review of a RIR dated 12/23/18 at 8:00 PM, documented the resident fell trying to use the bedside commode in another resident's room. A hand-written note on the form documented would be toileted after meals. Review of a RIR dated 02/2/19 at 8:00 PM, documented resident was found on the floor of the facility's living room, near the public restroom door, after trying to use the bathroom. A hand-written note on the form documented the resident had been receiving a diuretic medication for the past three days as the reason for his/her fall. Review of a RIR dated 02/4/19 at 8:40 AM, documented resident fell when s/he stood from his/her wheelchair and attempted to walk. A hand-written note on the form documented the resident was provided with a busy blanket. Review of a RIR dated 02/4/19 at 10:00 PM, documented resident fell in his/her room when trying to get himself/herself up from the bed. A hand-written note on the form documented s/he was taken to the emergency room (ER) for evaluation and diagnosed with [REDACTED]. Review of a RIR dated 02/13/19 at 8:46 PM, documented' resident fell in his/her room by his/her bed. A hand-written note on the form documented s/he was provided with safety education as was outlined in his/her care plan. Review of a RIR dated 02/14/19 at 8:46 PM, documented resident was found on the floor in the staff restroom. A hand-written note on the form documented s/he was taken to the ER, where she was found to have an elevated blood pressure and was started on [MEDICATION NAME]. Review of a RIR dated 02/19/19 at 11:46 PM, documented resident fell trying to get out of bed to use the restroom. A hand-written note on the form documented the facility planned to continue toileting the resident. Review of a RIR dated 03/13/19 at 9:45 PM, a documented resident was found on the floor in front of his/her wheelchair. The facility documented they planned to complete a Physical Therapy (PT) evaluation. Review of R20's care plan, dated 03/14/19, indicated s/he fell from her Rock and Go wheelchair, and PT was to evaluate that chair for positioning. Review of a RIR dated 04/1/19 at 9:16 PM, documented the resident fell while trying to stand from his/her wheelchair. A hand-written note on the form documented the resident had already been given a Rock and Go wheelchair. Review of a RIR dated 05/1/19 at 2:45 AM, documented the resident fell trying to get out of bed. A hand-written note on the form documented the non-skid backing was added to the resident's impact mat. On 5/7/19 at 10:00 AM, during an interview with the Acting Director of Nursing (DON) and Administrator, they confirmed R20 had fallen a number of times, and that each time the facility added a new intervention. However, the Acting DON and Administrator were unable to show how the facility had increased the level of supervision provided to the resident to prevent further falls. The Administrator stated while s/he had worked at the facility for quite some time, s/he had only been in his/her position as an Administrator for one week. The Acting DON stated another person had been in the DON role for most of these incidents, and s/he did not know, beyond what was documented, what had been done to increase supervision. On 5/8/19 at 5:45 PM, the Nurse Consultant provided the Resident Incident Reports, and stated there was a hand-written notation of the facility's corrective action and plan to prevent further falls on each form. The Nurse Consultant stated that though the facility did not document interventions that increased the level of supervision when R20 continued to fall, s/he felt the facility had identified and implemented interventions that were appropriate. The facility's Accidents and Supervision policy, implemented 11/1/17, documented, Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of Supervision: a. defined by type and frequency. b. Based on the individual resident's assessed needs and identified hazards in the resident environment. This complaint substantiates SC 22.

Based on policy review, record review and interview, the facility failed to ensure there was an indication for the use of antipsychotic medications, behavior monitoring was in place for three of five resident reviewed for unnecessary medications. This affected three of five (Resident (R)18), R25 and R10) of five sampled residents whose clinical records were reviewed for unnecessary medications; and target behaviors, for which antipsychotic medication was administered, were monitored for one resident, (R25) of five sampled residents whose clinical records were reviewed for unnecessary medications. The facility's Resident Census and Conditions of Residents, dated 05/06/19, documented a total of nine residents received antipsychotic medication. Findings include: The facility's Unnecessary Drugs - Without Adequate Indication for Use policy, implemented 11/07/19, documented: .Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: Adequate monitoring for efficacy.Documentation will be provided in the resident's medical record to show adequate indications for medication's use and the [DIAGNOSES REDACTED]. The facility's Behavior Management policy, implemented 11/01/17, documented: .Behaviors should be documented clearly and concisely by facility staff. Documentation should include specific behaviors, time and frequency of behaviors, observation of what may be triggering behaviors, what interventions were utilized, and the outcomes of the interventions. 1. Review of the physician's orders [REDACTED]. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD), of 03/14/19, documented the resident had a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident had severe cognitive impairment. The MDS documented the resident had no hallucinations or delusions and had exhibited no behaviors during the seven days prior to the ARD. The MDS documented the resident had received antipsychotic, antianxiety, and antidepressant medication on seven of seven days prior to the ARD. The Care Plan, reviewed/revised on 03/14/19, indicated R25 had problems related to her depression, anxiety and episodes of crying. An intervention for the problem was to Monitor effectiveness/side effects of medications as ordered. The physician's orders [REDACTED]. The order documented behaviors and side effects of the medication were to be charted. The original order for the [MEDICATION NAME] was dated 01/11/19. The Behavior/Intervention Monthly Flow Records documented the target behaviors which were monitored for the use of [MEDICATION NAME] were as follows: 01/2019 - [MEDICAL CONDITION], fighting, withdrawn/depressed, continuous crying 02/2019 - depressed/cries/withdrawn, yells/resists care, [MEDICAL CONDITION] 03/2019 - [MEDICAL CONDITION], fighting, confusion/crying 04/2019 - crying/yelling, resistant to care 05/2019 - hallucinations, crying, [MEDICAL CONDITION] On 05/09/19 at 11:58 AM, the above findings regarding behavior monitoring for R25 were reviewed with the Acting Director of Nursing (DON). When asked the behavior(s) for which the resident was administered [MEDICATION NAME], the Acting DON stated, S/he cries, s/he is resistive to care and fights. The Acting DON was shown the behavior monitoring sheet for 05/2019 and was asked if the behavior of fighting and/or resistive to care were being monitored. S/he stated the resident being resistant to care was not a target behavior listed on the 05/2019 behavior monitoring sheet. On 05/09/19 at 12:51 PM, The Nurse Consultant was shown the Behavior/Intervention Monthly Flow Records and was asked if the monitoring of the resident's behaviors for which [MEDICATION NAME] was used was inconsistent. S/he stated the target behaviors listed on the Behavior/Intervention Monthly Flow Records were inconsistent because the 05/2019 form did not list the target behavior of fighting and/or resistance to care. 2. R18's Face Sheet documented s/he was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. R18's physician's orders [REDACTED]. On 2/19/19, a Consultant Pharmacist Communication to Physician documented, Re: Antipsychotic Diagnosis - Justification for Use . An anti-psychotic medication should be used only for the following conditions/[DIAGNOSES REDACTED]. None of the [DIAGNOSES REDACTED]. The consultation report continued, [DIAGNOSES REDACTED].g., fear, continually yelling, screaming, distress associated with end-of-life, or crying); a significant decline in function; and/or substantial difficulty receiving needed care (e.g., not eating resulting in weight loss, fear and not bathing leading to skin breakdown and infection. The physician signed the form on 3/14/19. R18's Behavior Monitors for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) 2019 all documented the resident was monitored each shift for Paranoia, Hallucinations, Delusions, Mild Anxiety, and Uncooperative, with zeroes recorded for the first two target behaviors, and the behavior monitor for uncooperative left blank. R18's Behavior Monitor for (MONTH) 2019 documented Paranoia, Hallucinations, Delusions occurred three times on day shift, on each (MONTH) 1 and (MONTH) 3; and on night shift on (MONTH) 2, 3, 8, 11, 14, 15, and 20. In all cases, this behavior was documented as altered with non-pharmacological interventions. Mild Anxiety was also noted occasionally throughout the month, also documented as easily altered with non-pharmacological interventions. The third behavior of Uncooperative was blank. In (MONTH) 2019, the target behaviors on R18's Behavior Monitors changed. The first target behavior was Agitation, Yelling, and was noted on day shift on (MONTH) 17 and 24, and on night shift (MONTH) 11, 12,14, and 21. All behaviors were documented as easily alterable. The second target behavior identified was Restless Hitting, and documented twice on day shift and once on night shift, all easily altered. In (MONTH) 2019, the target behaviors for R18 changed once again, the first target behavior was Hallucinations, Delusions, and the second was Yelling Cursing. Both behaviors were noted on the first through third of the month and were easily alterable. On 5/9/19 at 8:50 AM, the SSD stated s/he was responsible for tracking residents receiving [MEDICAL CONDITION] medications, and initiating behavior monitoring. The SSD stated R18 had delusions that his/her son/daughter was a small child, or s/he had no money so needed to leave. The SSD stated R18 was on [MEDICATION NAME] for dementia with behaviors and had been admitted to the facility on that medication. The SSD stated the physician's orders [REDACTED]. The SSD stated R18 could get pretty anxious when his/her delusions occurred but was unable to describe his/her behaviors beyond that. On 05/9/19 at 12:08 PM, the Nurse Consultant stated the facility did not take the use of antipsychotic medications for residents with dementia lightly, but when you've tried everything, and nothing is working, we've got to do something. The Nurse Consultant stated that during the last recertification survey, R18 sat and cursed at the surveyors the whole week, and as recently as a year ago was completely out of control. The Nurse Consultant stated s/he felt the use of an antipsychotic medication for R18 was justified, although perhaps the documentation did not show that. 3. Review of R10's Face Sheet, located in the front of the resident's clinical record, revealed the facility admitted the resident on 09/06/16 with [DIAGNOSES REDACTED]. Review of Physician Orders, dated (MONTH) 2019, revealed R10 was ordered [MEDICATION NAME] 2 mg/ml by mouth daily for [MEDICAL CONDITION]. Continued review of the order revealed the order indicated the resident's behavior and side effects was to be charted. Review of R10's Behavior/Intervention Monthly Flow Record, dated (MONTH) 2019, revealed for the behavior of Paranoia, it was documented the resident did not have any episodes of the behavior for the month. Continued review revealed for the behavior of Hallucinations, it was documented the resident did not have any episodes of the behavior for the month. Review of R10's Behavior/Intervention Monthly Flow Record, dated (MONTH) 2019, revealed for the behavior of Hallucinations, it was documented the resident did not have any episodes of the behavior for the month. Continued review revealed for the behavior of Yelling/Crying, it was documented the resident did not have any episodes of the behavior for the month. Review of Consent for Use of Psychoactive Medication Therapy, dated 02/13/19, revealed the resident's representative gave consent for the use of [MEDICATION NAME]. Continued review revealed Specific Condition to be Treated, Other was marked with Unspecified [MEDICAL CONDITION] documented. Observation, on 05/07/19 at 3:33 PM, revealed R10 lying in bed, eyes closed and call light in reach. Observation, on 05/07/19 at 5:00 PM, revealed R10 lying in bed, with his/her eyes closed. Continuous observation, on 05/08/19 from 10:14 AM until 11:27 AM, revealed R10 lying in bed, on the left side of his/her back, with his/her eyes closed. Observation, on 05/09/19 at 7:45 AM, revealed a Certified Nursing Assistant (CNA) in R10's room taking the resident's vital signs. Continued observation revealed R10 lying in bed, with his/her eyes open. Observation, on 05/09/19 at 7:55 AM, revealed R10 lying in bed, with his/her eyes closed. Observation, on 05/09/19 at 8:05 AM, revealed CNA7 waking R10 up and asking him/her if s/he was ready for breakfast. Continued observation revealed R10 stated, yes. Observation, on 05/09/19 at 8:12 AM revealed R10 lying in bed with his/her eyes closed. Interview, on 05/08/19 at 11:00 AM, with CNA6, revealed to his/her knowledge, R10 does not have outraging behaviors. Continued interview revealed s/he has never seen the resident have a behavior other than him/her refusing showers or refusing to get out of bed. The CNA stated R10 talked to himself/herself sometimes. Interview, on 05/08/19 at 11:08 AM, with RN4, revealed when they have taken R10 off of the [MEDICATION NAME] in the past, s/he has been verbally aggressive, physically aggressive towards staff and had hallucinations, like having bugs in his/her ear. Interview, on 05/08/19 at 2:45 PM, with the facility's Medical Director, revealed at times R10 is either pretty lethargic or acting out and it had been difficult when trying to find the middle ground with her medication. Interview, on 05/09/19 at 11:00 AM with CNA7 revealed s/he was the resident's regular aide when s/he worked. Continued interview revealed the resident would not be able to hit anyone due to the functioning ability of his/her arms. The CNA stated his/her behaviors are refusing care, but s/he did not really see that as a behavior but was the resident's preference and right. Further interview revealed s/he had observed the resident saying things like, I don't have a tongue and sometimes s/he talks about his/her childhood. The CNA further stated, when the physician downgraded the resident's medication of [MEDICATION NAME], the resident was more alert, refused care more, and did same stuff that did not make sense and since they have increased it back, s/he was calmer and more willing to take a bath. Interview, on 05/09/19 at 3:45 PM with Registered Nurse (RN) 3, revealed before the resident's physician ever put the resident on [MEDICATION NAME], s/he was verbally abusive to staff and noncompliant when it came to take his/her medication. RN3 states the physician did decrease his/her [MEDICATION NAME] at one time; however, s/he started hallucinating and the resident's son/daughter told him/her it was early stages and if it was not increased again s/he would once again be verbally abusive to staff and noncompliant. The RN stated when it was increased back to 2MG, the resident was not terribly agitated but there was some agitation. After the increase back to 2 mg, the resident was more compliant and much nicer with the increased [MEDICATION NAME]. The RN further stated it had been a long time since s/he had seen any anger or verbal abuse from him/her. Interview, on 05/09/19 at 4:15 PM with the facility's Consultant Pharmacist, revealed [MEDICAL CONDITION] alone is not an indication of use for [MEDICATION NAME], but it is usually with another [DIAGNOSES REDACTED]. Further interview revealed R10 was not one of their most alert residents and a side effect of [MEDICATION NAME] was sedation; however, R10 had been on the medication so long, s/he did not believe the resident would experience that effect of the medication. The Pharmacist stated the resident's overall medication regimen of antipsychotics had been slowly reduced over the years. The Pharmacist further stated s/he had no documentation the resident was a harm to himself/herself or others and the last documented evidence of that would be the end of the year of (YEAR). Continued interview revealed the resident telling someone to get out of his/her room or refusing medications would not be an indication of continued use. Interview, on 05/09/19 at 5:10 PM, with the Administrator revealed it was the facility's practice before an antipsychotic is given, three failed nonpharmacological interventions have been attempted. Continued interview revealed if there was no documented evidence of behaviors such as distress or harm to self or others, the facility would adhere to the pharmacy recommendations and complete a Gradual Dose Reduction (GDR) attempt.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident's physician was immediately notified during a change of the resident's condition for one of 17 sampled residents (Resident (R) 32). Observation on 05/06/19 revealed R32 yelling in pain related to his indwelling catheter. Review of nursing progress notes revealed on 05/07/19, the nurse documented blood tinged urine in the resident's catheter drainage bag with small blood clots present; however, the facility did not notify the residents physician until 05/08/19. Findings include: Review of the facility's policy titled, MD Notification, dated 04/13/15, revealed the Physician would be notified for any acute change in condition, and any changes in a resident's status that the nurse deems necessitates notification of the physician. Continued review of the policy revealed at no time would it be acceptable or interpreted that no response means no changes in orders; however, there must be some communication between the facility nurse and the physician and/or his staff. Review of R32's Face Sheet, located in the front of his clinical record, revealed the facility readmitted the resident on 10/23/18 with [DIAGNOSES REDACTED]. Review of R32's quarterly Minimum Data Set (MDS) revealed the facility assessed the resident to have the appliance of an indwelling catheter. Review of Physician Orders, dated (MONTH) 2019, revealed the resident was ordered hospice services. Continued review of the physician's orders [REDACTED].#16FR w/ 30ML Bulb for the [DIAGNOSES REDACTED]. Observation, on 05/06/19 at 11:30 AM, revealed R32 yelling from his room I am hurting. My penis is hurting. Continued observation revealed a CNA immediately going into the resident's room to find the residents catheter tubing wrapped around his foot rest of his wheelchair. Further observation revealed the CNA unwrapping the tubing from the wheelchair and immediately notifying the resident's nurse. Review of R32's Nursing Progress Notes, dated 05/07/19 at 11:38 AM, revealed the resident to have blood tinged urine in his catheter bag with small blood clots. Continued review of nursing progress notes dated 05/08/19 at 7:27 AM, revealed the resident's Foley Catheter was patent and draining dark brown/red urine. Interview, on 05/08/19 at 10:52 AM, with Registered Nurse (RN) 4, revealed the resident was transferring himself the other day and got his catheter tubing caught on his wheelchair causing him to pull on his catheter. Continued interview revealed s/he thinks that is what is causing his dark red and blood in his urine. Further interview revealed the resident's hospice nurse was aware of the resident's condition and the hospice Medical Director knows about the resident's condition because the hospice nurse always keeps in contact with them. RN4 stated s/he had not notified the resident's facility physician because s/he notified the hospice nurse. Interview, on 05/08/19 at 2:49 PM, with the facility's Medical Director, who is also R32's attending physician, revealed s/he would not expect to be notified if the hospice physician was notified because s/he was part of the resident's medical team. Interview, on 05/08/19 at 3:18 PM, with the acting Director of Nursing (DON) revealed it was his/her expectation they would have notified the facility's on-call physician immediately. Continued interview revealed it was important the on-call physician would have been notified because R32 had a change of condition. Interview, on 05/08/19 with R32's Hospice Nurse, revealed s/he had seen the resident on 05/07/19 and was told about the trauma related to resident's catheter getting pulled. Continued interview revealed s/he did not notify the hospice physician. Interview on 05/09/19 at 5:10 PM, with the Administrator revealed it was his/her expectation for acute changes in a resident's condition, the physician would have been notified.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents had the right to be free from any physical restraints for one of 17 sampled residents (Resident (R) 21). R21 was ordered a pommel cushion which prevented the resident from independently rising out of the wheelchair. Additionally, the resident had a device in place which s/he could not remove easily. However, there was no documented evidence the facility assessed the resident for the restraints; and no documented evidence the facility obtained consents for the use of the restraints from the resident's representative. Findings include: Review of the facility's policy titled, Restraint Policy, dated 11/28/16, revealed each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Continued review of the policy revealed physical restraints were defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Further review of the policy revealed physical restraints may include but not limited to: a. leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays the resident cannot remove easily; and using devices in conjunction with a chair or merry walker, such as trays, bars, or belts that the resident cannot remove easily, that prevent the resident from rising or leaving the chair/walker. The policy revealed, the compliance guideline of Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint. The policy also revealed a physician's order alone is not sufficient to warrant the use of a restraint and the facility was responsible for the appropriateness of the determination to use a restraint. Additionally, the policy revealed, the facility shall explain to the resident or in the case of a resident who is incapable of making decisions, the resident's legal representative, the potential risks, and benefits of using a restraint, not using a restraint and alternatives to restraint use. Potential negative outcomes should also be explained including, but not limited to: a. Decline in physical functioning; b. Decreased muscle condition; c. Contractures; d. Increased risk for infection; e. Pressure sores; f. [MEDICAL CONDITION]; g. Agitation; h. Incontinence; i. Potential accident hazard; j. Loss of autonomy and dignity; k. Withdrawal or reduced social contact. Review of R21's Face Sheet, located in the resident's clinical record, revealed the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of R21's Physician Orders, dated (MONTH) 2019, revealed the resident was ordered Pommel Cushion to Chair (Per Hospice). Continued review of the resident's physician orders revealed an order for [REDACTED]. revealed no documented evidence of any other devices to be attached to the resident's wheelchair other than the pommel cushion. Review of the resident's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/19, revealed a cognitive evaluation was attempted; however, the resident was unable to complete the interview and the facility assessed the resident's cognitive skills for daily decision making to be severely impaired. Continued review of the MDS revealed the resident was assessed to need extensive assistance from one staff person for transfers (how resident moves between surfaces including to or from wheelchair). Further review of the MDS revealed the facility assessed the resident to have no impairment of Functional Limitation in Range of Motion. R21's MDS also revealed the facility assessed the resident as not using any physical restraints including equipment attached or adjacent to the resident's body that the individual could not remove easily which restricts freedom of movement or normal access to one's body. Review of R21's Clinical Record, specifically the Assessments section, revealed no documented evidence an assessment had been completed for the use of a pommel cushion or foot board to determine if the device would be considered a restraint Review of R21's Care Plan, revealed the problem, need, strength, potential concern of I need assistance with my ADLs (Activities of Daily Living) as evidenced by, I use assistive devices: WC (wheelchair), pommel cushion to high back WC. Continued review of the care plan revealed goals which included, I desire to maintain ADL self-performance levels as evidenced by no decline in stated level through next review date; and I will not develop any complications related to decreased ADL self-performance through next review. The residents care plan included the approach of, Provide me with adaptive/safety equipment needed; high back WC with pommel cushion. Observation, on 05/06/19 at 10:10 AM, in R21's room revealed the resident sitting in a wheelchair, with a pommel cushion in the seat of the wheelchair and a device attached to the wheelchair keeping the resident's feet elevated. Observation on 05/07/19 at 2:12 PM, revealed R21 being propelled down the 100 hall by a Certified Nursing Assistant (CNA) 6, with a pommel cushion being used. Interview, on 05/07/19 at 2:15 PM, with CNA6 revealed the resident has a pommel cushion that is to be used when the resident is in his/her wheelchair. Continued interview revealed the resident also has a foot board that attaches to the wheelchair. The CNA stated s/he did not know if the foot board was physician ordered, but the resident's son/daughter brought the foot board into the facility to be used on the resident's wheelchair to keep his/her legs elevated to prevent skin tears. CNA6 stated the resident's pommel cushion is for safety because it keeps him/her from sliding out of her wheelchair and stops him/her from standing up. Further interview with CNA6 revealed prior to the resident having the pommel cushion, s/he could independently stand up from the wheelchair. The CNA further stated it is not that they do not want him/her standing up, but they do not want him/her to break a hip, because once the resident was up s/he could walk, but s/he was unsteady. The CNA stated s/he had to take the resident's foot board off of the wheelchair during mealtime and has not put it back on the wheelchair yet. Observation, on 05/07/19 at 2:22 PM, with CNA6 and CNA7, revealed when R21 was prompted by CNA6 to stand up, the resident attempted to stand up independently but could not get over the horn of the pommel cushion. Interview, on 05/07/19 at 2:43 PM, with CNA7 revealed s/he was familiar with R21 and assists staff with his/her transfers. Continued interview revealed the resident did have a device that attached to the resident's wheelchair to keep the resident's feet off the ground. CNA7 stated the resident could not get up from the wheelchair when the device was attached to the resident's wheelchair. The CNA further stated the resident's son/daughter brought the attachment into the facility. Interview, on 05/09/19 at 5:10 PM, with the Administrator revealed if a device is used on a resident's wheelchair, it was his/her expectation the resident would be evaluated for the use of the device, risks versus benefits should be completed and documentation that consent was obtained from the resident or their representative. The Administrator stated it was his/her expectation the devices R21 was using would have been evaluated by the facility's therapy department. Further interview revealed prior to the survey team identifying the devices as restraints, the facility had not completed an assessment of risks versus benefits including consents for the devices and there was no physician's order for the foot board.

Based on record review, interviews and facility files, the facility failed to prevent the neglect of one of three residents reviewed for falls. Resident #1 was transferred incorrectly resulting in a [MEDICAL CONDITION]. The findings included: Cross refer to F282 related to the failure of the facility staff to follow Resident #1's care plan. Cross refer to F323 related to the failure of the facility to provide adequate supervision to Resident #1 to prevent injury. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Nurse's Note dated 12/17/14 at 4:30 PM that stated, "Resident noted on shower room floor with staff CNA (Certified Nursing Assistant) present. Call light pressed alerting staff to imidiate (sic) Assistance. 2 Nurses and 2 CNAs Responded. Resident assessed. No bleeding, no hematomas noted. Resident voiced pain with grimace (sic) Left hip and knee. Resident stabilized - EMS (Emergency Medical System) called. ...A&O (alert and oriented) x 3 able to voice self. Resident denys Hitting Head. Neuro Check protocol initiated R/T (related to) CNA states s/he hear her/his Head hit Side Rail of shower. Resident Vehement that her/his hip hurt, that s/he did not hit her/his head, CNA states s/he was able to break resident's fall. EMS Exit building with Resident on stretcher. 5 PM Res A&O x 3. Spouse... notified VIA Telephone re (regarding) fall". Nurse's Note of 12/21/14 stated the resident returned from the hospital. The Nurse's Note of 12/22/14 at 3:00 PM stated the resident's left [MEDICAL CONDITION] dressing to incision site was dry and intact. Review of the Plan of Care Kardex of December 2014 that the (Certified Nurse Aides) CNA's used to know the amount of assistance a resident required revealed the resident required a 2 person assist with transfers. Review of the resident's Care Plan revealed Potential for Falls was identified 11/26/13. The care plan had been updated with reviews and resident falls. A care plan approach for the falls was "Transfer with 2 person assistance". On 4/28/15 at approximately 6:05 PM, CNA #2 was interviewed by the surveyor. The CNA stated, "I went to the shower room to see if s/he (CNA #4) needed help." The CNA stated that CNA(#4) was sweating and pale. CNA #2 asked CNA #4 if s/he needed some water. CNA #4 stated she wanted a Pepsi and gave CNA #2 the money. CNA #2 left the shower room to obtain the drink. When the CNA returned to the shower room the resident and CNA #4 were no longer by the sink. "I took a few more steps and saw the resident in the shower stall on the floor. I asked her why she didn't wait for me to get back. 'You know I came in here to help you but you wanted something to drink.' S/he said s/he thought s/he could transfer her/him. S/he said she lowered him down. S/he (Resident #1) said s/he fell . When I came in (the shower room) the nurses were already there. S/he was a 2 person transfer for the shower. We always did a 2 person transfer with her/him." On 4/30/15 at approximately 11:45 AM CNA #4 was interviewed via phone by the surveyor. CNA #4 confirmed s/he transferred the resident by her/himself.

Based on record review and interview, the facility failed to follow the care plan for one of three resident's reviewed for falls. Resident #1 with a potential for falls identified as a problem area on her/his care plan was to be transferred with the assistants of two persons. The resident was transferred by one person, which resulted in a fall with a [MEDICAL CONDITION]. The findings included: Cross refer to F224 related to Resident #1 not receiving the care s/he required for safe transfer. Cross refer to F323 related to the failure of the facility to provide adequate supervision to Resident #1 to prevent injury. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Nurse's Note dated 12/17/14 at 4:30 PM. "Resident noted on shower room floor with staff CNA (Certified Nurse Aide) present. Call light pressed alerting staff to imidiate (sic) Assistance. 2 Nurses and 2 CNAs Responded. Resident assessed. No bleeding, no hematomas noted. Resident voiced pain with grimace (sic) Left hip and knee. Resident stabilized - EMS (Emergency Medical System) called. ...A&O (alert and oriented) x 3 able to voice self. Resident denys Hitting Head. Neuro Check protocol initiated R/T (related to) CNA states s/he hear her/his Head hit Side Rail of shower. Resident vehement that her/his hip hurt, That s/he did not hit her/his head, CNA states s/he was able to break resident's fall. EMS exit building with resident on stretcher. 5 PM Res A&O x 3. Spouse... notified VIA telephone re (regarding) fall". Nurse's Note of 12/21/14 stated the resident returned from the hospital. The Nurse's Note dated 12/22/14 at 3:00 PM stated the resident's left [MEDICAL CONDITION] dressing to incision site was dry and intact. Review of the Plan of Care Kardex of December 2014 that the CNA's used to know the amount of assistance a resident required revealed the resident required 2 person assist with transfers. S/he required 1 (one) assist with bathing. Review of the resident's Care Plan revealed Potential for Falls was identified 11/26/13. The care plan had been updated with reviews and resident falls. A care plan approach for the falls was "Transfer with 2 person assistance". On 4/30/15 at approximately 11:45 AM CNA #4 was interviewed by phone by the surveyor. CNA #4 stated that s/he had asked different people for help and no one would help her/him. "I took her/him in the shower room and did how they told me to. I held on to her/him and moved the shower chair. S/he said s/he was slipping. I slid her/him down my lap to the floor. On the door I could have sworn it said one person."

Based on record review and interview the facility failed to ensure Resident #1 received adequate supervision and assistance to prevent injury, one of three residents reviewed for falls. The findings included: Cross refer to F224 related to Resident #1 not receiving the care s/he required for safe transfer. Cross refer to F282 related to the failure of the facility staff to follow Resident #1's care plan. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Nurse's Note dated 12/17/14 at 4:30 PM that stated, "Resident noted on shower room floor with staff CNA (Certified Nursing Assistant) present. Call light pressed alerting staff to imidiate (sic) Assistance. 2 Nurses and 2 CNAs Responded. Resident assessed. No bleeding, no hematomas noted. Resident voiced pain with grimace (sic) Left hip and knee. Resident stabilized - EMS (Emergency Medical System) called. ...A&O (alert and oriented) x 3 able to voice self. Resident denys Hitting Head. Neuro Check protocol initiated R/T (related to) CNA states s/he hear her/his Head hit Side Rail of shower. Resident Vehement that her/his hip hurt, that s/he did not hit her/his head, CNA states s/he was able to break resident's fall. EMS Exit building with Resident on stretcher. 5 PM Res A&O x 3. Spouse... notified VIA Telephone re (regarding) fall". Nurse's Note of 12/21/14 stated the resident returned from the hospital. The Nurse's Note of 12/22/14 at 3:00 PM stated the resident's left hip fracture dressing to incision site was dry and intact. Review of the History and Physical dated 12/24/14 stated, "The patient is complaining of left hip pain. The patient recently fell and sustained a fracture of the left hip and underwent open reduction internal fixation. Under the section History of Present Illness it stated, "...Apparently s/he fell in the shower at this long term care facility and was found to have a nondisplaced left hip fracture that was intratrochanteric in nature. S/he did undergo open reduction internal fixation. S/he has returned from hospital and is having pain in her/his left hip." Review of the Plan of Care Kardex of December 2014 that the (Certified Nurse Aides) CNA's used to know the amount of assistance a resident required revealed the resident required 2 person assist with transfers. S/he required 1 (one) assist with bathing. The Kardex was updated on 12/22/14, "Max Asst (maximum assistance) x 2 plus 1 person holding left lower extremity for transfers". Review of the resident's Care Plan revealed Potential for Falls was identified 11/26/13. The care plan had been updated with reviews and resident falls. A care plan approach for the falls was "Transfer with 2 person assistance". During Initial Tour on 4/28/15 at approximately 5:00 PM. The surveyor observed stars next to resident's names on the door to their rooms. Also next to the resident names was a x 1, x 2. During an interview with CNA #1 at approximately 5:15 PM, the CNA (certified nurse aide) stated the residents with stars by their name meant the resident was a fall risk. The x 1 and x 2 meant how much assistance was needed to transfer the resident. The CNA stated that the residents that had an "H" by their name required the hoyer lift. CNA #2 and CNA #3, in separate interviews with the surveyor, confirmed the explanation given by CNA #1 for the stars and the amount of assistance needed for transfers. On 4/28/15 at approximately 6:05 PM, CNA #2 was interviewed by the surveyor. The CNA stated, "I went to the shower room to see if s/he (CNA #4) needed help." The CNA stated that CNA(#4) was sweating and pale. CNA #2 asked CNA #4 if s/he needed some water. CNA #4 stated she wanted a Pepsi and gave CNA #2 the money. CNA #2 left the shower room to obtain the drink. When the CNA returned to the shower room the resident and CNA #4 were no longer by the sink. "I took a few more steps and saw the resident in the shower stall on the floor. I asked her why she didn't wait for me to get back. 'You know I came in here to help you but you wanted something to drink.' S/he said s/he thought s/he could transfer her/him. S/he said she lowered him down. S/he (Resident #1) said s/he fell . When I came in (the shower room) the nurses were already there. S/he was a 2 person transfer for the shower. We always did a 2 person transfer with her/him." On 4/30/15 at approximately 11:45 AM CNA #4 was interviewed via phone by the surveyor. CNA #4 stated that s/he had asked different people for help and no one would help her/him. "I took her/him in the shower room and did how they told me to. I held on to her/him and moved the shower chair. S/he said s/he was slipping. I slid her/him down my lap to the floor. I turned the call light on and no one came. I laid him/her down and went and got the nurse, then they all came to help. On the door I could have sworn it said one person."

Based on record review, interviews and policy review titled "Abuse Prevention, Investigation and Reporting" revised 8/07 and "Fall Management Program" the facility failed to provide the necessary care and services to avoid physical harm to 1 of 1 residents reviewed for abuse. Resident #1 sustained an open head injury requiring emergency medical treatment from a fall that occurred from improper utilization of side rails. The findings include: The facility admitted Resident #1 with the [DIAGNOSES REDACTED]. Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively impaired. The MDS further specified that Resident #1 was total dependent with bed mobility and was total dependent with transfers requiring two person assist. No previous falls/fall history was noted on the resident's MDS. On 10/26/14 at approximately 8:00 PM, review of the facility provided incident report dated 10/18/14 at 9:50 PM revealed the "resident was noted on the floor lying to the right side of bed wedged in between furniture. Resident noted to have a large amount of blood behind head. Undetermined how incident occurred." Review of the initial 24 hour report submitted by the facility to the State Agency documented the incident as an injury of unknown origin stating "Resident "rolled out of bed" sustained injury to top of his/her head require 15 staples." The initial 24 hour report further noted: "Certified Nursing Assistant (CNA) stated that s/he had resident in bed. S/he had performed pericare-went to bathroom (b/r) to get denture cup-heard "bang" noted resident lying on floor-bleeding from head. Sent to ER (emergency room ) 15 staples to laceration on top of head. Complaint of (c/o) leg pain on 10/19/14. Sent back to hospital and was admitted ...." Review of Licensed Practical Nurse #3 witness statement on 10/26/14 at approximately 8:00 AM revealed, "on 10/18/14 side rail to right side of bed noted being down, but not sure if left side of rail was up or down at the time of incident. Review of Resident #1's care plan on 10/27/14 at approximately 3:00 PM revealed: Resident #1 has "increased potential for self care deficit in Activities of Daily Living (ADL's) related to history (hx) Debility and Right sided [MEDICAL CONDITION].." Further review of Resident #1's care plan noted, the resident "has increased potential for fall/injury related to hx [MEDICAL CONDITION] with Left sided [MEDICAL CONDITION], no safety awareness or ability to control balance and hx of [MEDICAL CONDITION], hx of fractured ankle, hx fall with fractured right clavicle.....Resident is totally dependent on staff for all transfers..."Approaches and intervention includes, but is not limited to "Transfer with 2 person assistance and hoyer lift, and 1/2 side rails as ordered." Review of Resident #1's "Restrain: Side Rail utilization-Data collection tool" dated 8/26/14 noted the resident having a history of falls, the resident is immobile (comatose, paralyzed, no spontaneous movement) and that the resident does not have enough mobility to turn or slide to one side. The fall risk assessments dated 8/26/14, 10/18/14 and 10/23/14 considered the resident as a high risk for potential for falls. The resident was noted as chair bound and unable to perform gait/balance functions. During an interview with Certified Nursing Assistant (CNA) #3 on 10/26/14 at approximately 7:40 PM, s/he stated "I came to the front desk I noticed the call light was going off in the resident room than I saw Licensed Practical Nurse (LPN) #3 down with the resident. I entered the room to assist. I took the roommate out of the room because s/he was highly upset. The bedrail on the right side was down on Resident #1's bed. This resident was suppose to have 1/2 side rails up x 2. CNA # 3 further stated when providing care to residents, when we leave, we are suppose to put rails back up and ensure they are secure. During an interview with Certified Nursing Assistant (CNA) #2 ( the alleged perpetrator) on 10/27/14 at approximately 10:22 PM s/he stated that "I transferred the resident from the wheelchair to bed without the assistance from another CNA." CNA #2 stated s/he then provided incontinent care to the resident, s/he then left to go into the bathroom and the resident fell out of the bed. CNA #2 confirmed that the side rails were down when s/he observed the resident lying on the floor. During an interview with Resident #1's Responsible Party s/he stated that the resident cannot roll or reposition self as s/he has been paralyzed for well over 30 yrs. The responsible party stated s/he felt the siderail could not have been up. Review of the policy titled "Abuse Prevention, Investigation and Reporting" last revised 8/07 noted: "The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion and misappropriation of personal property...."Neglect" means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." The policy titled "Fall Management Program" noted "The facility shall implement guidelines that limit and/or prevent the occurrence of falls within the parameters that can be controlled through structured program interventions. Minimize the severity of injuries sustained by an elderly individual resulting from a fall, and provide the professional staff with standards of practice that will enable them to perform effectively." Further review of the policy and procedure noted "Staff shall implement care approaches based on the resident's individual care plan."

Based on record review, interviews and review of the facility policies titled "Fall Management Program" the facility failed to ensure residents were provided with interventions and supervision to prevent falls that resulted in a fall with a significant injury for 1 of 4 residents reviewed for accidents and hazards. Resident #1 sustained a head laceration requiring 15 staples from a fall that occurred related to the improper use of 1/2 side rails. The findings included: The facility admitted Resident #1 with the [DIAGNOSES REDACTED]. Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively impaired. The MDS further specified that Resident #1 was total dependent with bed mobility and was total dependent with transfers requiring two person assist. No previous falls/fall history was noted on the resident's MDS. Review of Resident #1's care plan on 10/27/14 at approximately 3:00 PM revealed: Resident #1 has "increased potential for self care deficit in Activities of Daily Living (ADL's) related to history (hx) Debility and Right sided Hemiparesis.." Further review of Resident #1's care plan noted, the resident "has increased potential for fall/injury related to hx Cerebrovascular Accident with Left sided [DIAGNOSES REDACTED], no safety awareness or ability to control balance and hx of Osteoporosis, hx of fractured ankle, hx fall with fractured right clavicle.....Resident is totally dependent on staff for all transfers..."Approaches and intervention includes, but is not limited to "Transfer with 2 person assistance and hoyer lift, and 1/2 side rails as ordered." Review of Resident #1's "Restrain: Side Rail utilization-Data collection tool" dated 8/26/14 noted the resident having a history of falls, the resident is immobile (comatose, paralyzed, no spontaneous movement) and that the resident does not have enough mobility to turn or slide to one side". The fall risk assessments dated 8/26/14, 10/18/14 and 10/23/14 considered the resident as a high risk for potential for falls. The resident was noted as chair bound and unable to perform gait/balance functions. Review of the facility incident report and investigation on 10/26/14 at approximately 8:00 PM revealed the "resident was noted on the floor lying to the right side of bed wedged in between furniture. Resident noted to have a large amount of blood behind head. Undetermined how incident occurred." Further review of the Incident/Accident report noted that the resident required supervision. The incident had been noted to occurred on 10/18/14 at 9:50 AM. Licensed Practical Nurse #3 witness statement reviewed on 10/26/14 at approximately 8:00 AM revealed, "on 10/18/14 side rail to right side of bed noted being down, but not sure if left side of rail was up or down at the time of incident. Review of the initial 24 hour report submitted by the facility noted "Certified Nursing Assistant (CNA) started that s/he had resident in bed. S/he had performed pericare-went to bathroom (b/r) to get denture cup-heard "bang" noted resident lying on floor-bleeding from head. Sent to ER 15 staples to laceration on top of head. Complaint of (c/o) leg pain on 10/19/14. Sent back to hospital and was admitted ...." Review of the five-day follow up report on 10/27/14 at approximately 8:00 AM revealed details of reportable incident that noted, "CNA transferred resident to bed in preparation for night (hs). The CNA completed pericare. S/he went into bathroom to obtain denture cup when s/he heard a bang and noted resident lying on floor bleeding from head." Interventions that were in place prior to fall were noted as "Transfer with hoyer lift x 2, 1/2 side rails (sr) x 2 to aid in bed mobility and air mattress. During an interview with Certified Nursing Assistant (CNA) #3 on 10/26/14 at approximately 7:40 PM, s/he stated "I came to the front desk I noticed the call light was going off in the resident room than I saw Licensed Practical Nurse (LPN) #3 down with the resident. I entered the room to assist. I took the roommate out of the room because she was highly upset. The bedrail on the right side was down on Resident #1's bed. This resident was suppose to have 1/2 side rails up x 2. CNA further stated when providing care to residents, when we leave, we are suppose to put rails back up. During an interview with Certified Nursing Assistant (CNA) #2 (the alleged perpetrator) on 10/27/14 at approximately 10:22 PM s/he stated "I transferred the resident from the wheelchair to bed without the assistance from another CNA." CNA #2 stated s/he provided incontinent care to the resident,left to go into the bathroom and the resident fell out of the bed. CNA #2 confirmed that the side rails were down when s/he observed the resident lying on the floor. The policy titled "Fall Management Program" noted "The facility shall implement guidelines that limit and/or prevent the occurrence of falls within the parameters that can be controlled through structured program interventions. Minimize the severity of injuries sustained by an elderly individual resulting from a fall, and provide the professional staff with standards of practice that will enable them to perform effectively." Further review of the policy and procedure noted "Staff shall implement care approaches based on the resident's individual care plan."