Every finding on record at Frazee Care Center

Based on interview and document review, the facility failed to ensure the surety bond contained sufficient funds to insure and protect the resident's trust funds reviewed for personal funds. This deficient practice had the potential to affect all 26 residents who had personal funds with the facility. Findings Include:On [DATE] at 5:00 p.m., the residents' personal funds accounts were reviewed with the assistant administrator (AA)-A. AA-A confirmed the total amount of the residents' accounts was in the amount of 24,809.91 dollars. On [DATE] at 8:16 a.m., AA-A confirmed the facility's surety bond for the residents' personal funds had expired. AA-A indicated corporate office had not renewed after the past employee responsible had left. At 8:57 a.m., during a follow up interview AA-A indicated the surety bond for the residents' personal funds accounts was important to insure the residents' funds. AA-A stated it was expectation that the surety bond would be effective. AA-A confirmed 26 residents had personal fund accounts at the facility. Review of the Hartford Fire Insurance Company surety document dated [DATE], identified a surety bond for fifty thousand dollars was in effect [DATE] and ended on [DATE]. The facility policy titled Resident Trust Account dated 4/25, identified every resident had a right to manage their financial affairs. The facility would hold, safeguard, manage and account for the personal funds of the resident deposited with the facility. The facility would maintain a system that assured full and complete and separate accounting of each resident's personal funds and preclude any commingling of resident's funds with facility funds or with the funds of any person other than the resident. Personal funds more than $100 would be deposited into an interest-bearing account. The policy failed to identify the need to have a current surety bond for the total amount of the residents' accounts.

Based on observation, interview and document review, the facility failed to implement interventions for 1 of 1 residents (R28) who had repeated falls in the facility and remained at high risk for falls. In addition, the facility failed to ensure an environment that was free of accident hazards, related to hot water temperatures in 4 of 6 resident rooms (R6, R10,R13, R185) tested for safe water temperatures. This deficient practice had the ability to affect all 4 residents who used water from the water faucets. Findings include: FALLS R28's quarterly Minimum Data Set (MDS) dated [DATE], identified R28 had moderate cognitive impairment and had diagnoses which included diabetes mellitus (DM), hypertension (elevated blood pressure), and anxiety disorder. Indicated R28 required supervision with toileting and transfers. Identified R28 had one fall since the last assessment. R28's annual Care Area Assessment (CAA) dated 8/2/24, identified R28 had reduced safety awareness and required staff assistance during transfers and ambulation. Identified staff would proceed with supportive care and functional status would be addressed in care plan. R28's Fall Risk Screening Tool dated 9/23/24, identified R28 had three or more falls in the past six months and was at high risk for falls. R28's care plan revised 10/2/24, identified R28 had a history of falls and was non compliant with therapy recommendations for ambulation and transfers. R28's interventions included: encourage resident to use Front wheeled walker when transferring in room, Call light positioned for easy access and staff to place w/c legs in wheelchair bag on back of w/c when resident in room to prevent from tripping on them. Identified R28 required assistance with dressing, toilet use, and transfers. R28's Kardex undated, identified staff were to place wheelchair legs ( foot pedals) in wheelchair bag on back of wheelchair when resident was in her room to prevent from tripping on them. Review of R28's progress notes from 7/1/24 to 11/4/24, identified the following: -7/12/24 at 6:25 p.m., found sitting on the floor with legs out in front of her facing recliner. R28 stated she was transferring from wheelchair to the recliner and tripped and fell . R28 had several skin tears to right arm and elbow, no other injuries noted. Intervention: staff to place wheelchair legs in wheelchair bag when R28 was in her room. -8/4/24 at 8:00 p.m., found laying on left side with back towards the bed in room. R28 stated she was trying to turn oxygen concentrator on. two skin tears to left forearm, no other injuries noted. Intervention: oxygen concentrator moved next to bedside. -10/1/24 at 4:50 p.m., found on floor next to nightstand. Skin tear to left forearm, no other injuries noted. R28 was self transferring. Intervention: anti roll backs on wheelchair. -10/11/24 at 9:00 a.m., Found on floor in room. R28 attempted to place clothes in hamper and fell on floor. Intervention: Therapy screen, lowered back of wheelchair seat. During an observation on 11/4/24 at 1:27 p.m., R28 was seated in her room in a recliner with a wheelchair on her right side which had two foot pedals applied and a large empty black bag on the back of the wheelchair. During an observation on 11/4/24 at 3:47 p.m., R28 was coming out of the bathroom in her room seated in a wheelchair which had two foot pedals applied and a large empty black bag on the back of the wheelchair. During an observation on 11/5/24 at 8:48 a.m., R28 was seated in her room in a recliner with a wheelchair on her left side which had two foot pedals applied and a large empty black bag on the back of the wheelchair. During an observation on 11/5/24 at 9:53 a.m., R28 remained seated as noted above in her recliner with a wheelchair on her left side which had two foot pedals applied and a large empty black bag on the back of the wheelchair. During a joint interview on 11/5/24 at 9:55 a.m., nursing assistant (NA)-A and registered nurse (RN) -C verified R28 was seated in a recliner in her room with a wheelchair next to her which had two foot pedals applied. NA-A stated the foot pedals should not have been on R28's wheelchair because she had tripped on the wheelchair pedals and fell in the past. RN-C stated her expectation was that R28's wheelchair foot pedals would have been placed in the black bag behind R28's wheelchair anytime R28 was in her room. During an interview on 11/5/24 at 10:05 a.m., RN manager (RN-M) verified R28 had several falls in the facility. RN-C stated one of R28's falls had been related to R28 tripping over her wheelchair pedals while in her room therefore R28's wheelchair pedals were to be placed in the bag on the back of R28's wheelchair anytime R28 was not being transported by staff. RN-M indicated her expectation was that care planned interventions would have been followed. During an interview on 11/5/24 at 1:19 p.m., director of nursing (DON) verified R28 had several falls in the facility. Verified R28's wheelchair pedals were to be placed in a bag in the back of the wheelchair anytime R28 was in her room as a fall intervention. DON indicated her expectation was that care planned interventions would have been followed. HOT WATER On 11/4/24 at 12:02 p.m., during resident screening the water temperature in R6, R10, R13, and R185, felt very warm to the touch after running water for only a few minutes. On 11/4/24 at 12:32 p.m., maintenance director (MD) verified the water in R6, R10, R13, and R185's room felt too hot and used a thermometer to measure the water temperatures using the facility thermometer in resident rooms registered as follows: -R6's room [ROOM NUMBER] water was 122.2 degrees F. -R10's room [ROOM NUMBER] water was 122 degrees F. -R13 room [ROOM NUMBER] water was 122.2 degrees F. -R185 room [ROOM NUMBER] water was 122 degrees F. During an interview on 11/4/24 at 2:40 p.m., registered nurse (RN)-C verified all four residents were at risk for potential burns when the water was too hot. During an interview on 11/5/24 at 8:00 a.m. MD verified the above rooms were too hot according to State and Federal guidelines. MD stated he had completed random audits of water temps in the past month. MD stated at some point in the last month, the aerators ( a device that screws into a faucet to control the amount of water that comes out of the faucet) had been adjusted so there was more hot water coming from the faucets than should have been which could affect the temperature of the water coming from the above faucets. MD stated his expectation was that the water temperatures in all resident rooms would not exceed federal guidelines as water over 120 degrees F. had the potential to burn someone. During an interview on 11/5/24 at 1:16 p.m., administrator stated his expectations were that the water temperatures would remain within the Federal guidelines. Review of a facility policy titled Accidents/Falls-HDGR reviewed 11/23, identified the facility strived to promote safety, dignity, and overall quality of life for its residents by providing an environment that was free from any hazards for which the facility had control and by providing appropriate supervision and interventions to prevent avoidable accidents. Identified, resident care plans should be evaluated and updated with each fall with a new and applicable intervention based on root cause. The focus was to be on prevention and maintaining a safe environment. further identified the resident's individualized care plan was to be updated with any changes or new interventions post fall/incident/accident, communicated to appropriate staff, and implemented. The facility policy Water Temperatures dated 1/22, identified [NAME] Care Center would check hot water temperatures at least once a week randomly to ensure water temperatures were between 105-120 degrees F. (or as specified by State requirements). Indicated staff were to check resident rooms at the end of each wing on a rotating basis per facility policy.

Based on observation, interview and document review, the facility failed to accurately code the oral/dental section of the Minimum Data Set (MDS) for identified dental issues for 1 of 1 residents (R13) reviewed for dental services. Findings include: R13's quarterly MDS dated [DATE], identified R13 had severe cognitive impairment, and diagnoses which included: Alzheimer's disease, anxiety, and depression. R13's significant change MDS dated [DATE], identified R13 had no natural teeth or fragments. R13's significant change Care Area Assessment (CAA), dated 2/15/24, identified R13 lacked natural teeth, did not report complications and denied need for dental check-up at that time. Identified R13 wore upper dentures and staff were to assist with cleaning and placement as needed and R13 refused lower dentures. R13's Dental/Oral Data Collection Tool dated 5/6/24, identified R13 only wore upper dentures, no teeth lower jaw, and did not wish dental visit as nothing had worked in the past and was fine. R13's Dental/Oral Data Collection Tool dated 8/5/24, identified R13 only wore upper dentures, no teeth lower jaw, and did not wish dental visit as nothing had worked in the past and was fine. R13's Dental/Oral Data Collection Tool dated 8/22/24, identified R13 had own teeth and upper partial. R13 was seen by ATD hygienist, likely root tips in upper right (UR) and decay in upper left (UL). R13 mandible (lower jaw) was edentulous (toothless) with minimal ridge remaining. R13's Dental/Oral Data Collection Tool dated 11/4/24, identified R13 only wore upper dentures, no teeth lower jaw, and did not wish dental visit as nothing had worked in the past and was fine. R13's care plan revised 8/20/24, identified R13 was at risk for complications with deficits with activities of daily living (ADL)s related to current medical/physical status. R13's interventions included set up, assist of one as needed for hygiene and oral care completed. R13's care plan identified at risk for complications with dental status, and upper dentures and no teeth on bottom. Interventions included to coordinate arrangements for dental care, transportation as needed/as ordered. provide dental care as needed. R13's Apple Tree Dental Oral/Dental Assessment Form dated 8/22/24, identified likely root tips in upper right UR and decay in upper left UL. Mandible was edentulous with minimal ridge remaining. R13 would like to see doctor of dental surgery (DDS) for broken teeth. During an observation on 11/4/24 at 11:40 a.m., R13 was sitting in recliner in room, eyes closed, dressed in street clothes. Partial was noted in water in dental cup by sink. During an interview on 11/6/24 at 9:30 a.m., registered nurse (RN)-A confirmed R13's Dental/Oral Data Collection Tool had been completed on 11/4/24. R13 stated R13 had upper dentures, did not want dental visit and staff assisted her to brush her dentures. RN-A reviewed R13's electronic medical record, verified R13 was seen by Apple Tree Dental in August and FM-A wanted R13 to be seen by DDS for root tips in UR and decay in UL. At 12:31 p.m., during follow up interview, RN-A verified had just assessed R13, and verified R13 had two upper natural teeth that needed some treatment and R13 wore a partial. RN-A stated MDS's were completed off site and RN-A confirmed her assessment completed on 11/4/24, was not accurate. During an interview on 11/6/24 at 12:06 p.m., director of nursing (DON) confirmed the above findings of R13's Dental/Oral Data Collection Tool dated 11/4/24, and MDS was not accurate. DON stated the expectation was assessments and MDS were to be completed accurately. The facility policy titled Nursing Documentation (General) revised 2/23, identified the facility would document in a standardized manner of the care and services provided to a resident. The policy identified MDS completion as per Centers for Medicare & Medicaid Services (CMS) and Medicare guidelines. Back-up documentation from nursing staff was also completed.

Based on interview and document review, the facility failed to provide arrangements for follow-up care with a dentist for 1 of 1 residents (R13) reviewed for dental care. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had severe cognitive impairment, and diagnoses which included: Alzheimer's disease, anxiety, and depression. R13's significant change MDS dated [DATE], identified R13 had no natural teeth or fragments. R13's significant change Care Area Assessment (CAA), dated 2/15/24, identified R13 lacked natural teeth, and did not report complications and denied need for dental check-up at that time. Identified R13 wore upper dentures and staff were to assist with cleaning and placement as needed and R13 refused lower dentures. R13's Dental/Oral Data Collection Tool dated 8/22/24, identified R13 had own teeth and upper partial. R13 was seen by ATD hygienist, likely root tips in UR and decay in UL. R13 mandible (lower jaw) was edentulous (toothless) with minimal ridge remaining. R13's Dental/Oral Data Collection Tool dated 11/4/24, identified R13 only wore upper dentures, no teeth lower jaw, and did not wish dental visit as nothing had worked in the past, and was fine. R13's care plan revised 8/20/24, identified R13 was at risk for complications with deficits with activities of daily living (ADL)s related to current medical/physical status. R13's interventions included set up, assist of one as needed for hygiene and oral care completed. Identified at risk for complications with dental status, and upper dentures and no teeth on bottom. Interventions included to coordinate arrangements for dental care, transportation as needed/as ordered. Provide dental care as needed. R13's Apple Tree Dental Oral/Dental Assessment Form dated 8/22/24, identified likely root tips in upper right (UR) and decay in upper left (UL). Mandible was edentulous with minimal ridge remaining. R13 would like to see doctor of dental surgery (DDS) for broken teeth. R13's progress notes reviewed from 8/1/24 to 11/6/24, identified the following; -8/22/24 at 11:31 a.m., R13 seen today by ATD hygienist. Likely root tips in upper right UR and decay in UL. R13 would like to see DDS for broken teeth. -9/24/24 at 4:34 p.m., writer followed up with family member (FM)-A regarding resident dental hygienist review. FM-A suggested to follow through with R13 to be seen by DDS for evaluation. R13's progress notes lacked follow up for DDS evaluation was scheduled or completed. During a telephone interview on 11/04/24 at 12:39 p.m., family member (FM)-A indicated the facility had spoken to her about having R13 seen by a dentist and she had stated she wanted the appointment to be scheduled. FM-A was not aware if an appointment had been scheduled. During an interview on 11/6/24 at 9:30 a.m., registered nurse (RN)-A stated R13 had upper dentures, did not want a dental visit and staff assisted her to brush her dentures. RN-A reviewed R13's electronic medical record, verified R13 was seen by Apple Tree Dental in August and FM-A wanted R13 to be seen by DDS. During an interview on 11/6/24 at 10:10 a.m., social services director (SSD)-A confirmed a call had been placed to FM-A and had agreed R13 was to be seen by DDS. SSD-A stated it was tied up in paper work, and stated she had not yet finished faxing the request for R13 to be scheduled to be seen by DDS. SSD-A confirmed an appointment had not been scheduled. During an interview on 11/6/24 at 12:06 p.m., director of nursing (DON) stated SSD scheduled follow up appointments and transportation. DON confirmed R13 and FM-A had wanted a follow up appointment with DDS to be scheduled. DON stated if there were no sores or concerns noted, she would expect dental appointment requests be followed up on within a couple of weeks. DON indicated if the family or resident gave the approval to be seen by DDS, DON would expect the appointment to be scheduled within a couple of weeks. DON confirmed an appointment for R13 had not been completed. The facility policy titled Dental Services, revised 8/22, identified the community provided or obtained, from an outside resource, routine and emergency dental services to meet the needs of each resident. The community would assist the resident in making appointments by arranging transportation to and from the dentist's office.

Based on interview and document review, the facility failed to submit complete and accurate data for staffing information based on payroll during Quarter 4 (July 1st-September 30th, 2023) to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This deficient practice had the potential to affect all 33 residents residing in the facility. Finding include: Reviews of the Payroll-Based Journal Report (PBJ) [NAME] report 1705D Quarter 4 from 7/1/23-9/20/23, identified excessively low weekend staffing. Review of the staffing timecards identified staff, their position, and total hours worked. During the review of time cards from 7/1/23-9/20/23, revealed a shortage on 7/23/23, from 3:20 p.m. to 6:54 p.m. On 2/12/24 at 2:47 p.m., the administrator provided a change of schedule slip for 7/23/23. The change of schedule slip identified the director of nursing (DON) came in to cover the shift for registered nurse (RN)-D. The change of schedule slip was signed by DON and RN-D on 7/23/23. A review of the facility's schedule slips and timecards identified discrepancies with the low weekend hours between facility schedules, timecards and the PBJ report. During an interview on 2/12/24 at 10:23 a.m., the administrator stated the DON covered the shift on 7/23/23. The DON received a salary and did not punch a time card when she worked. The administrator verified without the DON providing a timecard punch, the date submitted to the PBJ was inaccurate. Review of a policy titled PBJ-Payroll Based Journal dated May 2020, indicated the community would electronically submit the CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

Based on observation, interview, and document review, the facility failed to ensure confidential information was not readily available for all residents, staff, and visitors to view for 17 of 17 residents (R26, R3, R21, R28, R86, R6, R11, R22, R5, R14, R27, R8, R31, R9, R30, R20 and R10) residing on the 100's wing whose confidential information was observed to be visible on two open computer screens and a resident care sheet in a common area. Findings include: During an observation on 2/12/24 at 11:26 a.m., a resident care sheet for the 100's unit was observed on top of the medication cart with the sheet facing right side up and information visible to anyone walking by. Resident care sheet identified first and last names for R26, R3, R21, R28, R86, R6, R11, R22, R5, R14, R27, R8, R31, R9, R30, R20 and R10 , room numbers, vitals and medication notes. Registered nurse (RN)-A returned to the medication cart at 11:31 a.m., wrote on the resident care sheet, and kept the care sheet information right side up with the information still visible. RN-A opened electronic medical record (eMAR) documentation system, moved over to another medication cart and opened the eMAR documentation system. Resident information including names, room numbers and diagnoses from residents who resided in the 100's wing as noted above, were visible on the computer screen. RN-A walked away from both medication carts, entered the medication room behind the nurses's station and closed the door. The screen from the eMAR remained open and the care sheet remained visible to others who walked by. RN-A returned to the medications carts, walked around the front of both medication carts and down the hall into the therapy room while the screen from the computer and care sheet continued to be visible to others who walked by. RN-A returned to the medication carts at 11:36 a.m., reviewed the open eMAR documentation system on the medication cart RN closed the laptop on the medication cart. RN-A moved over to the other medication cart and started to dispense medications. RN-A dispensed medications, locked the laptop screen on the medication cart, placed a kleenex box over the care sheet and walked down the 100's hallway. Both medication carts were located in front of the nurses station at the end of the 100's wing hallway. Five unidentified staff and two visitors were observed passing the front of both medication carts during the observation. During an interview on 2/13/24 at 9:31 a.m., RN-A indicated she was unaware she had left the residents' care sheet visible and computer screens open when she walked away from the medication carts. RN-A confirmed she walked away from both carts to provide assistance elsewhere. RN-A revealed she used the resident care sheet to track residents' vitals and store information about medication administration. RN-A indicated it was important to ensure residents' personal information was not visible to others and RN-A would be more cautious with personal information. 48740 During an observation on 2/12/24 at 11:21 a.m., RN-B removed R10's medications from the medication cart located on the 200's wing. RN-B walked away from the medication cart while the computer screen remained open with R10's eMAR visible. RN-B went into the day room to administer R10's medications. During that time RN-B administered R10's medications, one resident wheeled up to the medication cart and had the potential to see R10's confidential eMAR information. During an observation on 2/12/24 at 11:26 a.m., RN-B removed R20's medication from the the medication cart. RN-B walked away from the mediation cart while R20's eMAR remained open. During the time R20's eMAR was open and unattended, one resident walked by the medication cart and had the potential to view R20's confidential eMAR information. During an interview on 2/14/24 at 2:42 p.m., RN-B stated her normal process was to close the computer or lock the computer screen when she left the medication chart. RN-B verified she did not keep R10's and R20's eMAR information confidential when she left the computer screens open and visible and walked away. During an interview on 2/13/24 on 1:26 p.m., director of nursing (DON) confirmed the above findings and indicated due to Health Insurance Portability and Accountability Act of 1996,(HIPAA) computer screens should always be locked and care sheets should not be left visible. DON stated her expectations were staff would follow the policy for privacy. Review of facility policy titled Privacy and Confidentiality revised 11/16, identified the resident had a right to personal privacy and confidentiality of his or her personal and medical records. The resident had a right to secure and confidential personal and medical records. Resident records were limited to the use of the staff and would be safeguarded at all times to ensure confidentiality. Review of facility policy titled Medication Administration revised 11/22, identified staff were to place medication administration books or laptop/computer on top of cart; when unattended records should be closed for privacy.

Based on observation, interview and document review, the facility failed to follow standards of practice related to medication administration for 1 of 1 resident (R6) observed to receive an inhalation medication, and 4 of 4 residents (R4, R13, R14, R15) observed for medication administration. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 was cognitively intact, and had diagnoses which included: chronic obstructive pulmonary disease (COPD), respiratory failure and heart failure. Identified R6 received oxygen therapy. R6's comprehensive care plan dated 2/13/24, identified R6 required staff assistance with dressing, hygiene and transfers. Indicated R6 had diagnosis of COPD, with goals which included: would be free of serious complications related to respiratory disease and following doctor of medicine (MD) orders. R6's Order Summary Report signed 1/16/24, identified Fluticasone-Salmeterol (steroid) Aerosol Powder Breath Activated 250-50 microgram (MCG)/dose-1 puff inhale orally two times a day for COPD. Rinse mouth after each use. During an observation on 2/13/24 at 7:13 a.m., R6 was dressed in street clothes seated in her electric wheelchair in front of a table in her room. Registered nurse (RN)-A entered R6's room carrying an oxygen tank, which she applied to the back of R6's wheelchair. RN-A observed R6 take her oral medications from two paper medication cups, while taking sips of water. Nursing assistant (NA)-A entered the room and asked R6 if she needed anything. RN-A instructed R6 to take two inhalers, one which included the Fluticasone-Salmeterol inhaler R6 took the puffs of inhalers as prescribed. RN-A took the two inhalers and exited the room. R6 was not observed to rinse her mouth out and RN-A had not instructed R6 to rinse her mouth as ordered after taking the Fluticasone-Salmeterol inhaler. During an interview on 2/13/24 at 9:16 a.m., R6 indicated she received the Fluticasone-Salmeterol inhaler twice a day, which she had used at home prior to coming to the facility. R6 confirmed she had not rinsed her mouth after receiving the inhaler earlier that morning. R6 stated she was aware she was supposed to rinse her mouth after its use and had rinsed her mouth after using the inhaler once in a while at her home. R6 indicated she had not been reminded by facility staff to rinse her mouth out after the inhaler administration for a couple of years. During an interview on 2/13/24 at 9:43 a.m., RN-A confirmed she had not instructed R6 to rinse her mouth after receiving the Fluticasone-Salmeterol inhaler. RN-A stated she had not seen the order instructions to rinse mouth after use. RN-A indicated it was important to rinse the mouth after a steroid inhaler was received to prevent mouth sores. During a phone interview on 2/13/24 at 11:45 a.m., pharmacy consultant (PC)-A stated it was very important to rinse the mouth after using a Fluticasone-Salmeterol inhaler because it was a steroid. PC-A indicated it could cause Thrush, a fungal infection inside the mouth. PC-A stated the label on the Fluticasone-Salmeterol inhaler should include instructions to rinse after use. PC-A indicated it was her expectation that nursing staff would instruct the resident to rinse their mouth after use, and if they were unable to rinse their mouth, staff would use a toothette to cleanse their mouth after use. PC-A stated she would include reminders in her monthly report to the facility. During an interview and observation on 2/13/24 at 12:14 p.m., director of nursing (DON) confirmed R6's Fluticasone-Salmeterol inhaler label included instructions to rinse mouth after use. DON stated it was important for residents to rinse their mouth after use to prevent problems with their mouth. DON stated her expectation was for nursing staff to follow R6's orders. R6's Fluticasone-Salmeterol inhaler box instructions which included: to rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it. R6's Fluticasone-Salmeterol inhaler pharmacy label instructions included: to inhale 1 puff into lungs twice a day (BID), rinse mouth after use. The facility policy titled Medication Administration revised 11/22, identified it was the community's policy to administer all medications and treatments in a safe and effective manner. The policy procedure instructions included staff were to read medication orders on the medication sheet and to compare the label with medication sheet. The policy lacked instructions for inhaled medication administration. In addition, the policy stated to proceed with the cart to the resident's room area, for solid medications, remove medication container (blister pack or bottle) and compare label with medication sheet. Place appropriate dosage into medication cup. Re-read label and medication sheet and return drug to its proper location (triple check). Administer medication to resident. Repeat procedure with each resident who was to receive medications. 49620 R4's physician order summary dated 1/31/24, identified the following medications were ordered: Antacid suspension 30 ml by mouth every six hours as needed. Cranberry tablet 400 mg by mouth daily. Dilaudid 2 mg by mouth twice daily. Doxepin 25 mg by mouth daily. Famotidine 20 mg by mouth twice daily. Fetzima 60 mg by mouth once daily. Haloperidol 2 mg by mouth once daily and 3 mg by mouth once daily. Levothyrozine 150 mcg by mouth once daily. Milk of Magnesia 30 cc by mouth every 24 hours as needed. Miralax 17 gm by mouth once daily. Senna Plus one tablet by mouth twice daily. Seroquel 200 mg by mouth once daily and 100 mg by mouth once daily. Simethicone 125 mg by mouth every four hours as needed. Trazodone 150 mg by mouth once daily. Tylenol 650 mg by mouth twice daily and twice daily as needed. Vistaril 50 mg by mouth three times daily. R10's physician order summary dated 12/19/23, identified the following medications were ordered: Buspirone 7.5 mg by mouth twice daily. Depakote sprinkles 250 mg by mouth at bedtime daily. Donepezil 5 mg by mouth daily. Effexor XR 225 mg by mouth daily. Lactulose 30 ml by moth daily and every 24 hours as needed. Levothyroxine 225 mcg by mouth daily. Lyrica 150 mg by mouth twice daily. Milk of Magnesia 30 ml by mouth every 24 hours as needed. Miralax 17 gm by mouth twice daily. Morphine sulfate oral solution 2.5 mg buccally (placing the medication between the gum and cheek) every two hours as needed and three times a daily. Namenda 10 mg by mouth twice daily. Oyster Calcium 500 mg by mouth three times a day. Relafen 750 mg by mouth twice daily. Risperidone 0.25 mg by mouth once daily and 0.5 mg by mouth once daily. Senna-Plus two tablets by mouth twice daily. Tylenol 650 mg by mouth four times a day. Vitamin D 2000 mg by mouth daily. R13's physician order summary dated 2/9/24, identified the following medications wre ordered: Senna Plus two tablets by mouth as needed. Remeron 15 mg by mouth daily. Metoprolol 25 mg by mouth twice daily. Metamucil one packet by mouth as needed daily. Melatonin 6 mg by mouth daily at bedtime. Magnesium Oxide 400 mg by mouth daily. Magnesium Citrate 10 ounces by mouth as needed every seven days if no bowel movement. Fluoxetine 80 mg by mouth once daily. Robitussin Mucus plus Chest Congestion 10 ml by mouth every four hours as needed. Glycopyrrolate 1 mg by mouth every six hours as needed. Furosemide 40 mg by mouth once daily. Divalproex Sodium 500 mg by mouth once daily. Ferrous Sulfate 325 mg by mouth once daily-do not crush. Metronidazole 500 mg by mouth twice daily for three days beginning 2/9/24. Eliquis 5 mg by mouth twice daily. Ciprofloxacin 500 mg by mouth twice daily for three days beginning 2/9/24. Aspirin 81 mg by mouth once daily. R14's physician order summary dated 12/19/23, identified the following medications were ordered: Aspirin 325 mg by mouth daily. DocQLace 100 mg by mouth daily. I-Vite multi-vitamin by mouth twice daily. Keppra 500 mg by mouth in the morning and 750 mg by mouth in the evening. Lipitor 10 mg by mouth daily. Metformin 500 mg twice daily. Norvasc 10 mg by mouth daily. Proscar 5 mg by mouth daily. Tylenol 650 mg by mouth every six hours as needed. During an observation and interview on 2/11/24 at 4:09 p.m., RN-C unlocked medication cart, opened second drawer from top which revealed two white paper medication cups with multiple medications already present in both of them. The paper cups were located at the rear of the drawer, sliding back and forth when drawer opened and closed, and were labeled with black marker and was illegible. RN-C stated, I am the only nurse on the 200 and 300 wing, you can watch my medication pass however I have many of them already dished up. RN-C stated the two paper medication cups were for R13 and R14. RN-C indicated he was unable to verify what medications were in each residents pre-dished medication cups and, stated, I would have to look up the residents medication orders to see what is ordered for the evening. In addition, RN-C indicated he was unable to verify what the black marker identified on the cups and stated, there are certain residents that I always pre-dish medications early and will give the medications later when they are due to be given. One medication cup was observed to have crushed medications only. RN-C unlocked the controlled medication drawer on the right side of medication cart which revealed two paper medication cups with multiple medications in each cup. The cups moved around in the drawer when opened, were labeled with a black marker which was illegible. RN-C stated the medication cups were for R4 and R10 and locked in the controlled drawer due to having controlled substances ordered. When asked why medications were pre-dished, RN-C stated, That's just how it is done in the nursing home. RN-C indicated he was unable to verify what medications were in each residents pre-dished medication cup without checking each residents medications orders. During an interview on 2/13/24 at 2:13 p.m., pharmacy consultant confirmed the standard of practice recommended not to dish up medications prior to administering them and medications should be given closest to the time ordered. During an interview and observation on 2/13/24 at 12:14 p.m., director of nursing (DON) confirmed R6's Fluticasone-Salmeterol inhaler label included instructions to rinse mouth after use. DON stated it was important for residents to rinse their mouth after use to prevent problems with their mouth. DON stated her expectation was for nursing staff to follow R6's orders. During an interview on 2/13/24 at 2:43 p.m., DON stated the expectation for nursing staff was they would not setup medications ahead of time and would not dish up narcotics or crush medications ahead of time. The practice could result in medication errors including a resident receiving the wrong medication and possible injury. R6's Fluticasone-Salmeterol inhaler box instructions which included: to rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it. R6's Fluticasone-Salmeterol inhaler pharmacy label instructions included: to inhale 1 puff into lungs twice a day (BID), rinse mouth after use. The facility policy titled Medication Administration revised 11/22, identified it was the community's policy to administer all medications and treatments in a safe and effective manner. The policy procedure instructions included staff were to read medication orders on the medication sheet and to compare the label with medication sheet. The policy lacked instructions for inhaled medication administration. In addition, the policy stated to proceed with the cart to the resident's room area, for solid medications, remove medication container (blister pack or bottle) and compare label with medication sheet. Place appropriate dosage into medication cup. Re-read label and medication sheet and return drug to its proper location (triple check). Administer medication to resident. Repeat procedure with each resident who was to receive medications. Review of the facility policy titled medication labeling and storage revised 11/22, lacked instructions on pre-dishing and storing medications in the medication cart prior to medication administration. Review of the facility policy titled medications-controlled revised 11/22, identified controlled substances were signed out upon dispensing of the medication.

Based on observation, interview, and document review, the facility failed to ensure personal laundry and linen were transported in a manner that prevented risk of contamination for 3 of 3 hallways observed for linen transportation. In addition, the facility failed to ensure hand hygiene occurred during the laundry and linen distribution. Further, the facility failed to ensure infection prevention practices including hand hygiene were followed during wound cares for 1 of 1 residents (R13) observed for wound cares. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. Review of Centers for Disease Control (CDC) guidance titled Hand Hygiene in Healthcare Settings reviewed 4/28/23, identified hand hygiene protected residents receiving care and helped prevent the spread of germs. During an observation on 2/12/24 at 9:24 a.m., housekeeping aid (HA)-B took one pair of pants and one shirt out of the uncovered linen cart, brought into R30's room, placed in closet, brought two hangers out of the room and placed the hangers on the outside handle of the cart. HA-B pushed the uncovered linen cart down the 100's hallway, took one pair of pants, one shirt out of the linen cart, brought into R5's room, placed in closet, brought two hangers out of the room and placed them on the outside linen cart handle. HA-B pushed the uncovered linen cart down the hallway, took one shirt, one pair of pants out of the linen cart, brought into R22's room, placed in closet and walked back to the cart. HA-B pushed the uncovered linen cart down the hallway to the 200's rooms. HA-B took two shirts from the linen cart, entered R10's room, placed into the closet, grabbed two hangers from closet and placed on linen cart handle. HA-B entered R1's room, picked a pair of socks off the floor, placed them into the hamper in R1's room, grabbed two hangers from closet and placed them on the linen cart handle. HA-B continued to push the uncovered linen cart down the hallway past R24 in a wheelchair, grabbed one shirt, one pair of pants from linen cart, brought into R25's room and placed into closet. R24 entered R25's room in wheelchair, HA-B used both wheelchair handles and wheeled R24 out of R25's room into R24's room. HA-B exited R24's room, went to the linen cart, grabbed one shirt, one pair of pants out of the linen cart, brought into R24's room and put them in the closet. HA-B grabbed two hangers from R24's room, assisted R24 with her glasses, exited R24's room and placed the hangers on the handle of the linen cart. An unknown resident was pushed by the open linen cart in a bath chair while HA-B removed one blanket from the linen cart, placed on her knee, grabbed another blanket from the linen cart and placed under her left arm. HA-B walked down the hallway with both blankets, entered R7's room, placed one blanket in the chair, exited room, walked into R1's room, placed the blanket in the chair and exited the room. HA-B walked back to the linen cart, pushed the uncovered linen chart down the hallway. HA-B removed one shirt and walked back down the hall and placed R7's shirt in the closet. HA-B returned to the linen cart and pulled the uncovered linen cart down the hallway to the 300's rooms. HA-B grabbed one shirt, one pair of pants from the linen cart, entered R18's room, placed clothing in closet, grabbed two hangers from closet and placed them on the linen cart handle. HA-B moved the uncovered linen cart further down the hallway, grabbed one shirt, one pair of pants, brought into R20's room, placed them in closet, grabbed two hangers from closet and hung them on the linen cart handle. HA-B grabbed one shirt, one pair of pants, brought into R13's room, placed them in closet, removed two hangers from closet and placed them on the linen cart handle. HA-B pulled the cover down over the cart and pushed the cart back to the laundry room. HA-B did not sanitize her hands and the cart remained uncovered during the entire observation. During an observation on 2/12/24 at 2:03 p.m., housekeeping supervisor (HA)-A was observed removing laundry from the laundry cart, delivered laundry to R2's room, placed laundry in R2's closet and exited R2's room. HA-A removed laundry from the cart, did not sanitize hands, delivered laundry to R4's room, placed laundry in R4's closet and exited R4's room. HA-A removed laundry from cart, knocked on R24's door, placed laundry in R24's closet and exited R24's room. HA-A returned to laundry cart in hall, removed laundry from cart, knocked on R25's door, placed laundry in R25's closet and exited R25's room. HA-A removed laundry from cart, delivered laundry to R29's room, placed laundry in R29's closet, assisted R29 to put glasses on, exited R29's room and returned to laundry cart without sanitizing hands. HA-A removed laundry from cart, knocked on R13's door, touched handles on R13's wheelchair to move out of way of closet, placed laundry in R13's closet and exited R13's room. HA-A removed laundry from cart, knocked on R7's door, placed laundry in R7's closet and exited R7's room. HA-A stopped in R1's room and visited with R1, exited R1's room with dirty laundry, returned to laundry cart and placed dirty linen on bottom shelf of laundry cart. HA-A removed laundry from cart, knocked on R23's door, opened door, placed laundry in R23's closet and exited R23's room. HA-A pushed laundry cart down hall, stopped at linen closet in hall, opened linen door, delivered four pairs of gripper socks to shelf in closet, closed linen door and pushed laundry cart down hall. HA-A removed laundry from cart, knocked on R18's door, placed laundry in R18's closet, exited R18's room and went directly to R20's room with the rest of the laundry observed being carried. HA-A knocked on R20's door, opened door, placed laundry in R20's closet and exited R20's room. R18 asked HA-A why she had not received lunch and was hungry. HA-A entered R18's room, visited with R18, then went into the dining room toward the kitchen and returned a few minutes later to R18's room followed by a dietary staff who brought food. HA-A pushed laundry cart to the laundry room. HA-A did not sanitize her hands during the entire observation. During an interview on 2/12/24 at 2:10 p.m., HA-A verified she removed laundry from the cart, placed the laundry in the residents' closets and did not sanitize her hands. HA-A stated the purpose of completing hand hygiene was to prevent the spread of infection between residents. During an interview on 2/13/24 at 7:47 a.m., HA-B verified she did not keep the laundry cart covered the entire time while transporting the cart down the hallway for rooms in the 100's, 200's and 300's. She revealed she did not keep the cart covered because the hallways are not vacuumed and she did not want the dust going into the clean linens. HA-B stated she carried residents clothing from the cart to residents rooms, hung in closet and grabbed hangers from closets. HA-B confirmed she walked down the 200's hallway with one clean blanket in her hand and one clean blanket tucked under the left arm to deliver to residents' rooms. HA-B indicated she only sanitized her hands at the beginning and then again at the end of the clothing pass. During a follow-up interview on 2/13/24 at 8:00 a.m., HA-B indicated she did not wear gloves when she collected soiled linen because she did not see the need to throw gloves away all the time. She stated she only sanitized her hands at the end of laundry pick-up and did not sanitize them in between residents. During an interview on 2/13/24 at 12:15 p.m., infection preventionist (IP) indicated she was not aware linen and laundry was being transported uncovered and staff did not sanitize their hands between residents. IP indicated her expectations were for staff to sanitize their hands between each resident during laundry distribution. IP stated she would expect staff to follow the rules and policies for laundry, handling laundry and dispensing laundry. IP stated she would expect staff to let someone in management know if they were unable to complete their jobs safely and while following infection prevention guidelines. 49620 During an observation on 2/11/24 at 5:53 p.m., R13 was observed laying in bed for wound care. Registered nurse (RN)-C entered R13's room for a scheduled wound dressing change. RN-C applied gloves, opened R13's dresser, removed saline solution and 4x4 gauze and placed onto bedside table. RN-C tore the top off three package's of 4x4 gauze. RN-C removed saline bottle cover and poured saline into the 4x4 packages, removed the 4x4's from the packages and placed the 4x4's into a stack on R13's bedside table. RN-C pushed the bedside table that was near the dresser over to R13's bed. RN-C removed a soiled dressing from R13's right knee. R13's knee was observed to be bleeding. RN-C applied pressure to R13's right knee with the soiled gauze. RN-C removed the soiled gauze and a few drops of blood from the actively bleeding wound went onto the bed sheets. RN-C used wound cleanser and sprayed the open wound on R13's knee, approximately a silver dollar amount of blood was observed to spray onto R13's bed sheets. RN-C set the wound cleanser bottle on R13's bedside table, the bottle was observed to have numerous splatters of blood present on the spout, handle and front of bottle. RN-C opened an ointment of bacitracin with soiled gloves, put gloved finger on end of ointment tube and expelled ointment onto his gloved finger. RN-C put ointment on right knee which was still actively bleeding. RN-C set ointment on bedside table, removed backing from a foam dressing with adhesive edges and applied to R13's right knee. RN-C put gloved finger on ointment, expelled ointment onto gloved finger and applied ointment to R13's left knee that had three abrasions each approximately the size of a penny and were left open to air. RN-C lowered the head of the bed using electric hand control and assisted trained medication aide (TMA)-A to roll R13 onto his left side. RN-C retrieved the same wound spray bottle from bedside table, sprayed two wounds on R13's left buttock and one wound on R13's right buttock area. RN-C used one single 4x4 dry gauze to dry all three wounds, placed ointment on gloved finger and applied to all three wounds. RN-C applied the three wet 4x4 gauze pads and placed one over each wound, opened two abdominal pad dressings and secured dressings with tape to buttocks. RN-C took gloves off, discarded into trash bin, picked up black marker from bedside table, dated and initialed R13's right knee dressing. RN-C assisted TMA-A to move R13 onto his back, put a blanket on R13 and raised the head of the bed using the electric hand control. RN-C set wound supplies on R13's dresser, left R13's room. RN-C was not observed to wash or sanitize hands when entering R13's room, during any of the wound cares, or prior to leaving R13's room. During an interview on 2/13/24 at 12:15 p.m., infection preventionist (IP) stated the expectation of nursing staff when completing wound cares was to practice good hand hygiene, remove gloves when needed and ensure the environment was sanitary. During an interview on 2/13/24 at 1:19 p.m., director of nursing (DON) indicated she was not aware laundry was being handled and transported as noted above. DON stated her expectations were for staff to be sanitizing or washing their hands before they entered a resident's room and when they left a resident's room. DON indicated staff were expected to follow the policies that had been put in place regarding transporting of linen and hand washing. Review of facility policy titled Linen Handling dated revised 11/2022, when handling, storing, processing, and transporting linens, facility personnel use procedures designed to prevent the spread of infection. Wash hands, apply gloves before handling soiled linen and hands are washed after handling dirty laundry and prior to handling clean laundry. Review of facility policy titled Handwashing revised 11/2022, identified the facility required staff to wash their hands after each direct resident contact for which handwashing was indicated by accepted professional practice. As per recommendations from the CDC guidelines. Alcohol-based hand sanitizers were the most effective products for reducing the number of germs on the hands of healthcare providers.

Based on observation, interview, and document review, the facility failed to ensure insulin pens were accurately dated when opened for 2 of 3 residents (R11 and R136) who received insulin injections and insulin pens were disposed of past expiration date for 1 of 3 residents (R9) who received insulin injections. Further, the facility failed to ensure correct labeling on one refrigerated medication in 1 of 2 refrigerators reviewed for medication storage. Findings include: R11 R11's quarterly review Minimum Data Set (MDS) dated [DATE], indicated R11 had diagnoses which included diabetes mellitus (DM), malnutrition and anxiety. Indicated R11 required moderate assistance of one staff with toileting and personal hygiene. R11's signed physician's orders from [DATE] to [DATE], indicated R11 a physician's order for lantus (long acting insulin medication to control blood sugar) 10 units in the morning (AM) and 10 units at bedtime (HS) / evening (PM). R11's order audit report from [DATE], indicated R11's order was for Insulin Glargine Subcutaneous Solution 100 units/ml, inject 10 units subcutaneously two times a day for DM. R9 R9's significant change MDS dated [DATE], indicated R9 had diagnoses which included end stage renal disease (disease of the kidneys), DM and anxiety. Indicated R9 required extensive assistance of one staff with toileting, transfers and personal hygiene. R9's signed physician's orders dated [DATE], lacked an order for Basaglar KwikPen Subcutaneous Solution 100 units/ml (long acting insulin medication to control blood sugar. R9's order audit report from [DATE], indicated R9's order for Basaglar KwikPen Subcutaneous Solution 100 units/ml, inject 7 unites subcutaneous one time a day for type 2 DM, hold and notify provider if blood sugar (BS) is below 80 had been discontinued. R136 R136's signed Order Summary Report dated [DATE], indicated R136 had a diagnosis of type 2 diabetes mellitus (DM) and had a physician's order for Insulin Glargine Subcutaneous Solution 100 units/ml (long acting insulin medication to control blood sugar, inject 25 units subcutaneously at bedtime for DM. During an observation and interview on [DATE] at 4:15 p.m., while completing medication storage of the medication carts with registered nurse (RN)-B, the top drawer of medication cart A1 contained an Insulin Glargine Subcutaneous Solution 100 units/ml insulin pen for R136 which was not dated. In the top drawer of medication cart A2, an Insulin Glargine Subcutaneous Solution 100 units/ml insulin pen for R11 was noted with no date and a Basaglar KwikPen Subcutaneous Solution 100 units/ml insulin pen for R9 which identified it had been opened on [DATE] and contained no expiration date. RN-B confirmed the outdated insulin pen and undated insulin pens . RN-B stated R11, R9 and R136 had current orders for insulin and stated yes we are giving them. RN-B indicated her usual process had been to open insulin pens and date them right away. RN-B stated she thought insulin pens were good for 30 days after opening and the facility used a cheat sheet do confirm expiration dates. During an interview on [DATE] at 2:13 p.m., pharmacy consultant (PC) indicated it was the responsibility of the facility to ensure all insulin pens were dated and discarded following manufacturer's recommendations. PC indicated Basaglar Solution Insulin pens, Lantus Solostar Solution Insulin pens and Insulin Glargine pens expired after 28 days being open at room temperature. PC stated her expectations were for the facility to have medications properly labeled with resident information and to follow manufacturer's recommendations for expiration dates. 49620 During an observation/interview on [DATE] at 4:55 p.m., registered nurse (RN)-C entered medication storage room, opened refrigerator and took out a box with a vial of Mantoux solution, (Tuberculin Purified Protein Derivative), verified the solution had been opened and accessed. RN-C confirmed the box and the vial did not have a date on them of when opened and placed into use. RN-C verified a label on the box and the vial stated to date when opened and discard after being opened for 30 days. During an interview on [DATE] at 2:13 p.m., pharmacy consultant (PC) indicated it was the responsibility of the facility to ensure all insulin pens were dated and discarded following manufacturer's recommendations. PC indicated Basaglar Solution Insulin pens, Lantus Solostar Solution Insulin pens and Insulin Glargine pens expired after 28 days being open at room temperature. PC stated her expectations were for the facility to have medications properly labeled with resident information and to follow manufacturer's recommendations for expiration dates. In addition, pharmacy consultant indicated the pharmacy applied a label on the Mantoux box and vial as a reminder to staff to date once opened and discard after 30 days of being opened. Pharmacy consultant verified the expectation of nursing was to date the Mantoux solution once opened and discard after 30 days of being opened. Stated per manufacturer direction, the stability of tuberculin purified protein derivative was for 30 days after opened and would then be discarded. During an interview on [DATE] at 2:43 p.m., director of nursing (DON) confirmed the above findings and indicated her expectations were for staff to follow facility policy and manufacturer's recommendations. DON stated she would expect staff to date all insulin pens when they were opened and discard when they expired. DON indicated she would expect all nursing staff passing medications to review expiration dates during medication passes. DON stated the facility did not have a process in place to ensure medications were being stored properly. In addition, DON verified the expectation of nursing staff would be to date the box and vial of Mantoux solution once opened. DON stated the solution would not be safe to use after 30 days of being opened. Review of facility policy titled Medication Labeling and Storage revised ,d+[DATE], medications were labeled in accordance with state and federal laws and include the expiration date when applicable. Labels included the residents name, drug name, dose, frequency, route instructions for use, and expiration date. Review of manufactures specifications for In-use Pen, store the pen you are currently using at room temperature [up to 86 Fahrenheit (F) (30 Celsius (C))] and away from heat and light. Throw away the pen you are using after 28 days, even if it still has insulin left in it. Review of manufacturer's specific for use, 3 ml single-patient-use SoloStar in use pen expires 28 days after opening. Review of manufacturer's specifications for use, 3 ml single-patient-use insulin glargine in use pen expires 28 days after opening. Review of facility policy titled, Drugs and Biological Storage-Labeling, dated [DATE], identified drugs and biologicals were to labeled in accordance with current accepted professional standards, including the appropriate accessory and cautionary instructions and the expiration data when applicable.

Based on observation, interview, and document review, the facility failed to ensure residents were assessed for the ability to self administer medications (SAM) for 1 of 3 residents (R3) reviewed for medication administration. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact. Identified R3 had diagnoses which included heart failure, anxiety and depression. Indicated R3 required moderate assistance of one staff with toileting and personal hygiene. Review of R3's electronic health record (EHR) revealed a SAM assessment had not been completed and R3 did not have an order for self administration of medications. R3's Physician's Telephone Orders dated 2/5/24, and signed 2/12/24, directed staff to administer DuoNeb (medication used to relax the muscles in the airways and increase air flow to the lungs) four times daily (QID) for seven days then as needed (PRN) for wheezing and shortness of breath (SOB). R3's Medication Administration Record (MAR) dated 2/1/24 to 2/9/24, indicated R3 was taking Ipratropium-albuterol inhalation solution (DuoNeb) 0.5-2.5 3 milligrams (mg) per 3 milliliters (ml). R3's order further indicated R3's order began on 2/5/24 at 8:00 p.m., and ended 2/12/24 at 4:00 p.m. R3's order for DuoNeb was changed to PRN following the physician's telephone order on 2/12/24. R3's care plan dated 12/21/23, indicated staff were to observe R3 for changes in cognition, level of alertness, confusion and forgetfulness. Identified staff were to reorient R3 as needed. During an observation on 2/12/24 at 11:33 a.m., registered nurse (RN)-A verified R3's DuoNeb order, retrieved the DuoNeb from the medication cart, locked the medication cart and walked to R3's room. RN-A knocked on R3's door, entered the room, explained the medication to R3, opened the DuoNeb and poured the solution into the nebulizer container. RN-A handed the nebulizer container to R3, turned the nebulizer machine on and informed R3 she would be back in ten minutes to shut the machine off. RN-A exited R3's room, returned to medication cart and signed off that the DuoNeb had been administered. RN-A stated R3 is only taking this medication for seven days so she just does it by herself. During an observation on 2/12/24 at 11:49 a.m., RN-A returned to R3's room, knocked on door, entered R3's room and shut the nebulizer machine off. RN-A took the nebulizer container from R3, disassembled the nebulizer container, washed it out in the sink and placed it on a wash cloth next to the nebulizer machine to dry. During an interview on 2/13/24 at 8:59 a.m., R3 stated she she had been receiving DuoNeb treatments since she acquired an illness. R3 indicated she did not know how often she was receiving the medication. R3 stated she had not been taught how to use the nebulizer machine. R3 verified nursing staff did not remain in the room with her while the treatment was being administered. She stated nursing staff turned the nebulizer machine on, handed her the nebulizer and left the room right after handing it to her. R3 indicated nursing staff returned to her room once the nebulizer treatment was completed to turn the machine off. During an interview on 2/13/24 at 9:27 a.m., RN-A verified R3's order for DuoNeb's for seven days. RN-A confirmed she set R3's nebulizer treatment up, handed the nebulizer container to R3, turned the nebulizer machine on and set her timer to return to R3's room when the treatment was finished. RN-A sated she had checked on R3 however did not stay in R3's room during the entire administration. RN-A confirmed R3 did not have a SAM assessment completed and did not have an order for self administration. RN-A stated if a resident did not have a SAM assessment or an order for self administration, staff were required to stay in the room during the entire administration. During an interview on 2/13/24 at 1:24 p.m., director of nursing (DON) confirmed the above findings and indicated staff should have been following the facility policy. DON stated her expectations were staff would assess residents for the ability to complete self administration of medications. DON indicated if the resident did not have a SAM assessment or physician's orders, staff were expected to remain with the resident during the entire administration. Facility policy titled Self Administration of Medications revised 1/23, indicated an individual resident may self-administer medication if the resident requested and the interdisciplinary team had determined that self-administration was clinically appropriate. Staff were to complete a self-administration of medication tool. If the team determined that self-administration was clinically appropriate, staff would obtain a physician's order for resident to self-administer each specific medication that the resident had been qualified to self-administer. In addition, staff would update the resident's care plan to indicate the resident's choice to self-administer medications.

Based on observation, interview and document review, the facility failed to ensure three years of survey results were readily accessible to residents and visitors. This deficient practice had the potential to affect all 33 residents currently residing in the facility. Findings include: During an observation on 2/12/24 at 10:00 a.m., a survey results book was located affixed to the wall in the main lobby of the facility, by the front door. The survey results book had survey results from the 2019, 2020, 2021, 2022, and 2023 recertification surveys. The survey results book lacked the deficiency from the 8/8/23, complaint investigation. During an interview on 2/12/24 at 10:23 a.m., assistant administrator (AA)-1 verified the 8/8/23, deficiency from the complaint investigation was not located in the survey book. During an interview on 2/12/24 at 10:31 a.m., administrator stated he was unaware the deficiencies from complaint investigations needed to be included in the survey results book for residents to review when requested. Review of a facility policy titled Examination of survey results dated May 2020, identified the three preceding years of surveys, certifications, and complaint investigations completed by the state and/or federal surveyors would be available for review.

Based on interview and document review, the facility failed to have a system in place to assure protocols for periodic evaluation (at least weekly), which include wound measurements and other wound characteristics, were completed and documented for 1 of 1 resident (R2) reviewed for pressure injury. Findings include: R2's significant change Minimal Data Set (MDS) dated [DATE], indicated R2 was admitted to the facility on [DATE], and diagnoses included anemia, end stage renal disease and had severely impaired cognition. Significant change MDS also indicated R2 did not exhibit any behaviors, was determined to be at risk of developing pressure ulcers and had two stage 2 pressure ulcers and one unstageable pressure ulcer. R2's care plan dated 1/31/24, identified R2 had actual complications with impaired skin integrity with interventions that included encouraging a high protein diet, staff to complete daily dressing changes and wound monitoring, provide education to R2 and family regarding offloading, waffle cushion for recliner, encourage nap in bed during day time, float heels, pressure reduction cushion in wheelchair, pressure reduction mattress on bed, heel protectors while in bed, and reposition every two hours while in bed or chair and as needed. R2 discharged the facility on 9/25/23. Review of R2's treatment administration record (TAR) dated 9/1/23 through 9/30/23, indicated R2 had an order for skin management requiring weekly body observation form to be completed every day shift, every two weeks for prevention as of 7/28/23. R2's Weekly Skin Check Tools indicated: -On 7/14/23, pressure wound to right outer ankle remained, and improvement has been noted as area was scabbed over and smaller in size. Right heel wound remained, and improvement was noted by a dry blister, no drainage, odor, warmth, or redness present and R2 denied having pain. -On 7/28/23, pressure wound to right outer ankle remains, and improvement noted as area had a scab and was smaller in size and nearly resolved. Right heel pressure wound remains improvement noted as the blister was gone and no odor, redness, warmth, or drainage present. -On 8/11/23, right outer ankle and right heel wounds remained, and see wound round documentation for further information. -On 9/8/23, right outer ankle and right heel wounds remained, and see weekly wound round documentation for further information. R2's record lacked evidence Weekly Skin Check Tool was completed every two weeks, as ordered, and lacked evidence of wound measurements and wound characteristics. R2's Weekly Wound Round Documentation indicated: -On 6/14/23, identified a stage 2 right outer ankle pressure wound which measured 0.75 centimeters (cm) x 0.5 cm and depth was 0.25 cm. Wound bed was noted to have granulation, surround tissue was intact, no drainage, odor, or undermining/tunneling present. Wound was identified to be stable. -On 6/28/23, identified a stage 2 right heel pressure wound which measured 4.5 cm x 4.2 cm and depth was 0. Wound bed was noted to have eschar, surrounding tissue was intact, no drainage, odor, or undermining/tunneling present. Further, wound was noted to be improving. In addition, R2's right outer ankle pressure wound was a stage two and measured 0.5 cm x 0.5 cm and depth was 0.1 cm. Wound bed was described as having epithelial tissue and granulation, surround tissue was intact, no drainage, odor, or undermining/tunneling noted. Wound was noted to be improving. -On 7/21/23, identified a stage 2 right heel pressure wound which measured 3.0 cm x 2.6 cm and depth was 0. Wound bed was noted to have eschar, surrounding tissue was intact, no drainage, odor or undermining/tunneling present. Wound was noted to be improving. Further, stage 2 right outer ankle pressure wound measured 0.3 cm by 0.2 cm depth was not identified. Wound base was noted to have eschar, surrounding tissue was intact, no drainage, odor, or undermining/tunneling was present. Wound was noted to be improving. -On 8/2/23, identified a stage 2 right heel pressure wound which measured 1.8 cm x 1.2 cm and depth was 0. Wound base was noted to have epithelial tissue and granulation, surround tissue was intact, no drainage, odor, or undermining/tunneling was present. Wound was noted to be improving. Further, R2's ankle wound was noted to have a scab and 0.1 cm eschar only. -On 8/10/23, identified stage 2 right heel pressure wound which measured 1.4 cm x 1.0 cm and depth was 0. Wound base was noted to have epithelial tissue and granulation, surround tissue was intact, no drainage, odor, or undermining/tunneling was present. Wound was noted to be stable. Further, R2's right ankle had a scab and was almost healed. -On 9/11/23, identified an unstageable right heel pressure wound which measured 4.3 cm x 4.1 cm and depth was 0. Wound base was noted to have eschar, surrounding tissue was intact, no drainage, odor, or undermining/tunneling was present. Wound was noted to be declining. Further, R2's right outer ankle wound measured 2 cm x 2 cm and depth was 0.2 cm. Additional information included nurse practitioner (NP)-A had assessed the wounds the last two weeks and staff were monitoring wounds closely. -On 9/14/23, identified an unstageable right heel pressure wound which measured 4.3 cm x 4.1 cm and depth was 0. Wound bed was noted to have eschar, surrounding tissue was intact, no drainage, odor or undermining/tunneling was present. Wound was noted to be declining. Further, R2's outer ankle pressure wound measured 3.5 cm x 2 cm and depth was 0.2 cm. -On 9/19/23, identified an unstageable right heel pressure wound which measured 4.5 cm x 4.3 cm and depth was 0. Wound bed was noted to have eschar, surrounding tissue was intact, no drainage, odor or undermining/tunneling was present. Wound was noted to be declining. Further, R2's right outer ankle pressure wound measured 2.2 cm x 2.3 cm and depth was 0.2 cm. R2's record lacked evidence of staff assessing R2's wounds on her outer ankle or heel at least weekly, as required. Review of R2's provider Progress Notes indicated: -On 8/2/23, R2 was seen by NP-A and had complaints of pain in right heel. R2 was admitted to the facility with an unstageable wound. The area had dried up and sloughed away. There was a remaining area that was scabbed. Further, progress note indicated the skin impairment was a right heel blister site healing which was measured approximately 1 cm and directed staff to continue dressing for protection. -On 8/23/23, R2 was seen by NP-A who noted R2 had a chronic wound to her right heel, which was unstageable, describing the wound as mostly dry occasionally some drainage. Staff were using a foam heel cup to the area. R2 was noted to have another area to the lateral surface of her right ankle, which was approximately the size of a dime, with 100% slough. R2 had reported some discomfort to the area. NP-A noted no concerns for erythema or infection. During an interview on 2/1/24 at 10:13 a.m., registered nurse (RN)-A stated licensed floor nurses were expected to update the director of nursing (DON) with concerns or updates related to any wounds. RN-A stated the DON was in the wound care nurse role and would assess including obtaining measurements of each wound weekly. However, RN-A stated licensed nursing staff at times have completed the wound assessments but only when asked by the DON. On 2/1/24 at 11:14 a.m., RN-B stated licensed nursing staff were expected to complete weekly skin assessments on each resident's bath day and notify the DON with concerns or changes. Further, RN-B stated if a resident had a wound identified the wound would be assessed weekly including obtaining measurements which would be completed by the DON who was overseeing all wounds at the time. RN-B stated licensed nurses were able to complete the wound assessment if the DON directed them to do so. On 2/1/24 at 1:33 p.m., DON stated due to position changes and hiring a new nurse manager the team was discussing delegation of tasks and who was going to oversee wounds. At this time, DON stated licensed floor nurse would be expected to update DON if there are any changes with a resident's wound when they complete the dressing changes/treatments. DON confirmed facility Weekly Wound Documentation was not completed weekly. If the wound was identified as acute or chronic would then determine how often the wound assessment was completed and if there have been no changes the wound would be assessment monthly. If the wound was identified as acute and needing constant observation or having signs of infection, then staff would be expected to complete the Weekly Wound Documentation weekly to ensure the wound was improving. Further, DON stated R2 had wounds on her feel that would heal then open back up again. DON confirmed R2's wounds were not chronic, and staff were not assessing them weekly, only if staff noted large changes. DON was not unsure why licensed staff did not complete wound assessments between 8/10/23 and 9/11/23 and was not aware of any concerns brought up by licensed staff regarding the wound getting worse. In addition, DON stated licensed nurses would be expected to complete Weekly Skin assessment for each resident on their scheduled bath day and if the resident was identified to have a pressure wound then the Weekly Wound assessment would be completed by the nurse manager and again stated if the wound was chronic the assessment would be completed monthly but if there were changes to the wound then the assessment would be weekly. On 2/1/24 at 4:15 p.m. NP-A stated R2 was admitted to the facility with the pressure wounds and other medical concerns had impacted wound healing. NP-A stated she was onsite at the facility weekly and staff would converse with her regarding residents with wounds. Further, NP-A stated she would expect an RN to assess each resident's wound once a week as well as with each dressing change and if there were any changes to the wound then would expect to be notified. Review of facility policy titled Pressure Ulcer/Skin Integrity revised 4/22, indicated facility would ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Skin inspections would be completed upon admission, and thereafter, a skin inspection would be completed to identify preexisting, or potential areas of skin breakdown and routine skin inspections would be completed and documented in the resident's electronic medical record. The frequency of skin inspection would be based on the resident's individual needs or risk factors. Further, policy indicated wound documentation was more detailed than routine skin documentation and shall include information related to the wound based on a clinical assessment. The policy lacked evidence of a process or staff direction on how often a wound should be comprehensively assessed and who was expected to complete the clinical assessment to meet regulatory requirements.

Based on observation, interview and document review, the facility failed to ensure 3 of 6 residents (R1, R2, R3) were appropriately re-assessed to safely smoke independently at the facility and failed to ensure implementation of smoking interventions. This resulted in an Immediate Jeopardy when R1 sustained fourth degree burns to the left side of face, left side of neck, left shoulder, left arm, left chest, left abdomen, and left upper leg when she was left outside to smoke with out a smoking apron on, dropped a spark from her cigarette on her left side which set fire to her clothing. The immediate jeopardy began on 6/10/23, at approximately 7:55 p.m. when R1 was found by staff outside the facility, under a covered patio, on fire resulting in hospitalization and fourth degree burns. The immediate jeopardy was identified on 6/15/23, and the administrator was notified of the immediate jeopardy on 6/15/23, at 4:10 p.m. The immediate jeopardy was removed on 6/12/23, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's Admission Record indicated she admitted to the facility on [DATE]. The Admission Record identified diagnosis that included hemiplegia (one-sided paralysis), hemiparesis (partial weakness or inability to move on one side of the body) and nicotine dependence. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she required limited assistance from staff for locomotion on and off the unit. R1's MDS indicated she had impairments of her upper and lower extremities on one side. R1's Smoking Evaluation Tool dated 2/24/23, identified the following question: Resident smokes safely (Does not allow ashes or lit material to fall while smoking, inhaling or holding smoking item. Remains alert and aware while smoking. Does not forget he/she is smoking or falls asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). The question was answered no, however the assessment indicated R1 was a safe smoker who could smoke independently and unsupervised and required a smoking apron. R1's Smoking Evaluation Tool dated 5/23/23, identified a question: Resident smokes safely (Does not allow ashes or lit material to fall while smoking, inhaling or holding smoking item. Remains alert and aware while smoking. Does not forget he/she is smoking or falls asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). The assessment indicated R1 could smoke independently or with set-up and indicated she must wear a smoking apron at all times. R1's care plan dated 10/4/22, indicated she had a tendency to be non-compliant with the facility smoking policy and procedure. The care plan directed staff to remind R1 of the potential negative outcomes related to her choice of not smoking in the dedicated area and wearing a smoking apron. The care plan further directed staff to provide reminders to wear the smoking apron. R1's care plan was revised 6/11/23, and identified a critical injury from smoking. The care plan indicated per assessment R1 was unable to smoke per facility policy. R1's Progress Notes identified the following: 2/13/23, Per nursing assistant (NA) on 2/11/23, R1 refused lunch so she could smoke. The NA went to follow up with R1 and noted R1 must have flicked an ash into her purse because it (purse) was smoking. The NA dumped out R1's purse and a few tissues were smoldering along with the purse. 2/15/23, Staff had a discussion with R1 about not being able to go outside to smoke until an assessment could be done. R1 voiced that she was safe to smoke and the previous incident had been an accident. Staff voiced concern that although it had been an accident, the outcome could have been much worse so for now R1 was unable to smoke. 2/24/23, Smoking evaluation was completed per R1's request so she could smoke again. The results were as follows: R1 could not bring a purse out to smoke. R1 would have smoking materials on the nurses cart at all times and could have one cigarette and lighter when she went out then had to return the lighter after. R1 was to dress warmly and could put phone for emergency in her right coat pocket. R1 must wear smoking apron. Will wear doorbell to alert staff when she needed assistance getting over the threshold outside and would not bring smoked cigarettes or butts back into the facility. R1 was directed to put the cigarettes out in the snow on the ledge and throw onto the snowy ground. 4/19/23, NA reported R1 was asking staff and other residents to pick up cigarette butts for her to smoke. 6/2/23, Staff discussed smoking privileges at the facility and concerns from family member that R1 could only have two cigarettes at a time when she went outside. 6/10/23, Trained medication aide (TMA) went outside to administer medications to R1. As the TMA got to the outside door he noted fire under the covered patio and when he got outside realized it was R1 who was on fire and ran toward her and attempted to pat the fire out on the left side of her neck. The TMA then began removing clothing that was on fire. The TMA used R1's soda to dump on her and the clothes to extinguish the fire. The TMA called for assistance and emergency services were called. R1 was flown to Hennepin County Medical Center. Per staff, R1 was last seen at about 6:00 p.m. coming inside the facility wearing a smoking apron. 6/12/23, R1's family member reported R1 had been switched to comfort focused care with a goal to return to facility. Staff was able to get information from the hospital nurse who reported R1 sustained 4th degree burns and required dressing changes multiple times per day. During observation on 6/16/23, at 8:07 a.m. R1 was lying in bed with her eyes closed. R1 had a blanket covering the lower half of her body. R1 had no hair, had multiple bandages covering part of her face and neck and bandages covering her entire left arm and hand. R2's Admission Record indicated an admitted [DATE]. The Admission Record identified diagnosis that included Hemiplegia, hemiparesis and tobacco use. R2's annual MDS dated [DATE], indicated he had intact cognition, required extensive assistance with transfers and supervision with locomotion. R2's MDS indicated he had impairments to both his upper and lower extremities on one side of his body. R2's Smoking Evaluation Tool dated 3/30/23, identified the following question: Resident utilizes ashtray safely and properly (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into the ashtray). The box was checked no however, the evaluation indicated R2 was a safe smoker and could smoke unsupervised. The use of a smoking apron was not indicated. R2's care plan dated 5/16/23, identified a risk for injury related to smoking. The care plan directed nursing to store smoking materials and indicated R2 required a smoking apron. The care plan was updated 6/11/23, and indicated all residents who smoke must be supervised. R2's Progress Notes identified the following: 4/7/23, Staff provided R2 with education about the facility smoking area and that he could not be smoking outside other residents windows. Staff reminded R2 that if he chose not to use the designated smoking area his privileges could be revoked. 5/5/23, R2 was seen outside tipped over in his wheel chair. R2 said his wheel went off the sidewalk onto the grass and caused his chair to tip over backwards. 5/15/23, NA reported R2 had gone out to smoke without a smoking apron which resulted in burn holes in the the mechanical lift sling and R2's pants. Staff had an in-depth conversation with R2 who stated, I am too lazy to put it on, but I will wear it if someone helps me put it on. Decision made to have R2's smoking materials placed in the medication cart so he would have to have a smoking apron put on. R3's Admission Record indicated she admitted to the facility on [DATE], with diagnosis that included muscle weakness. R3's significant change MDS dated [DATE], identified intact cognition. The MDS indicated R3 required supervision with locomotion on and off the unit and indicated she had lower extremity impairment on one side. R3's Smoking Evaluation Tool dated 5/15/23, indicated she could safely smoke independently but must request smoking materials from staff. R3's care plan dated 3/16/22, identified a risk for injuries related to smoking. The care plan directed staff to assess for safe smoking practices on admission, quarterly and as needed. R3's care plan was revised 6/12/23, to include all residents required to be supervised and have dedicated smoking times. R3's Progress Notes identified the following: 3/8/23, Staff found cigarette ashes in R3's bed, cigarettes on the floor in her room and it appeared R3 had put a cigarette out on the plastic part of her cigarette pack. R3 stated she did not remember lighting a cigarette in bed after being shown the ashes on her sheets. Staff reviewed the smoking policy with R3 and completed a smoking assessment. R3 continued to be a safe smoker but her cigarettes would be stored in the medication cart. 5/16/23, R3 fell out of her wheelchair outside while smoking . R3 stated she had been reaching down to get her cigarettes that she dropped. A NA found R3 face first on the ground. During interview on 6/15/23, at 1:45 p.m. the director of nursing (DON) stated smoking assessments were completed on admission, quarterly and if a policy change occurred. The DON said staff watched the resident while smoking to see how they did. The DON stated after R1 had the incident when she dropped the spark in her purse, she felt the interventions put in place at that time made R1 safe to continue smoking independently. The DON stated after R2 burned holes in his clothing he was assessed to need a smoking apron and felt that would make R2 safe to smoke independently also. When asked who monitored the residents to ensure the interventions were implemented the DON said she felt like the staff and the residents themselves were responsible. In regard to R3 falling out of her wheel chair while outside smoking and finding ashes in her bed along with burned plastic on her cigarette pack, The DON said staff removed R3's smoking materials and placed them in the medication cart. The DON was unable to articulate why supervision of smoking was not implemented following R1, R2 and R3's demonstrations of unsafe smoking. On 6/15/23, at 2:09 p.m. NA-A stated she remembered bringing R1 outside to smoke about 2:30 p.m. on 6/10/23, and she put a smoking apron on her. NA-A said she saw R1 at about 4:30 p.m. before dinner but did not recall seeing her after that time. NA-A said R1 could get herself out the door and said at that time there had been no restrictions on her smoking but said R1 needed to wear a smoking apron because she was one of the two residents that would burn themselves. On 6/15/23, at 2:14 p.m. NA-B stated she did not know how R1 had gotten outside and said R1 usually sat outside most of the day. NA-B said when she saw R1 just before 6:00 p.m. she had a smoking apron on and said when R1 went back outside she was not wearing one. NA-B said R1 had trouble getting over the threshold to get outside. NA-B said the only person staff worried about when smoking was R2 because he had burned a couple holes in the mechanical lift sling. NA-B said R1 and R2 were the only residents that needed a smoking apron. NA-B stated the incident with R1's purse was the reason she got the smoking apron. During interview on 6/15/23, at 2:22 p.m. TMA-A stated on the evening of 6/10/23, he went outside to bring R1 her medications. TMA-A stated when he got outside he saw a fire and initially thought it was the picnic table. He said when he got closer he realized R1 was on fire. TMA-A stated he tried to put the fire out and ended up ripping off R1's clothing, dumped her pop on her and radioed for help. TMA-A said he thought R1 had been outside for about an hour and had not been wearing a smoking apron when the fire started. TMA-A said R1 had been wearing a shirt, sweatshirt and a blue nylon scarf. Facility policy [NAME] Care Center Complex Resident Smoking Policy dated 5/5/21, indicated all residents who want to smoke or use tobacco products at the facility will be assessed by a nurse for safety and appropriateness upon admission to the facility, quarterly and as needed. Each resident will be assessed for physical, cognitive, mood and behavior factors that may affect a resident's ability to independently and safely smoke while at the facility. The policy identified the designated smoking area and indicated from 6:00 a.m. to 10:00 p.m. was open smoking. The past noncompliance immediate jeopardy began on 6/10/23. The immediate jeopardy was removed, and the deficient practice corrected on 6/12/23, after the facility implemented a systemic plan that included the following actions: - All residents in the facility who smoked were re-assessed for safety. - The facility implemented designated smoking times with staff supervision for all residents and implemented smoking audits. - The door leading out to the smoking area was equipped with a fire extinguisher, a fire blanket and additional smoking aprons. - The facility's smoking policy was updated to include: All residents will be supervised while smoking and taken outside at the designated times. - Staff education was implemented and ongoing and was verified through observation, interview and document review.

Based on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately documented in the clinical record to reflect the residents' current wishes which affected 1 of 17 residents (R20) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R20 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R20's electronic health record (EHR) main screen and orders identified R20 was to have CPR however, R20's updated POLST signed on [DATE], identified R20's wishes of do not resuscitate (DNR). The administrator, assistant administrator and director of nursing (DON) were notified of the IJ on [DATE], at 5:39 p.m. The IJ was removed on [DATE], at 1:55 p.m. when the facility had implemented corrective action, however non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R20's annual Minimum Data Set (MDS) dated [DATE], identified R20 had mild cognitive impairment and diagnoses which included: hypertension, emphysema (lung condition that causes shortness of breath) and Alzheimer's disease. R20's care plan revised [DATE], identified R20's advanced directives to be followed per medical provider (MD) orders. The care plan indicated the POLST would be reviewed as needed and placed in the front of R20's paper chart. R20's POLST signed by the medical provider on [DATE], identified DNR, scanned into R20's EHR. R20's POLST signed by the medical provider on [DATE], identified CPR, which was located in R20's paper medical record and in addition was scanned into R20's EHR. The paper chart lacked the most current updated POLST from [DATE]. Review of R20's EHR orders on [DATE], at 5:16 p.m. identified the order for CPR which had a revision date of [DATE]. The EHR lacked an order for DNR. Review of R20's progress notes from [DATE], to [DATE], identified the following: -[DATE], at 12:50 p.m. discussion with R20's guardian regarding R20's POLST and goals of care, provider felt R20 was more appropriate for DNR status as R20 did not desire any further medical interventions for care and did not wish to leave the facility. R20's guardian agreed and R20's POLST was changed to DNR. During an interview on [DATE], at 12:07 p.m. registered nurse (RN)-B indicated in the event a resident did not have a pulse or respirations, RN-B would refer to the resident's paper chart for code status. RN-B reviewed R20's paper chart and confirmed R20's POLST identified CPR was to be administered. RN-B stated the facility had instructed staff to follow the POLST in the paper chart. During an interview on [DATE], at 12:19 p.m. RN-A stated in the event of a resident experiencing cardiac arrest, staff were instructed to refer to POLST in the resident's paper chart. RN-A confirmed R20's POLST identified CPR and RN-A stated she would call 911 and begin CPR on R20 in the event of cardiac arrest. During an interview on [DATE], at 1:38 p.m. RN-C stated in the event a resident was not breathing or unresponsive, she would review the POLST in the resident's paper chart to determine code status. RN-C indicated the facility had provided education to staff to review the residents' paper charts to determine their code status. During an interview on [DATE], at 1:43 p.m. DON stated residents' POLST were completed with residents and/or their representative and their provider when they were admitted to the facility. DON stated the facility process involved completing the POLST with the resident or representative upon admission, make a copy of the POLST and placing in the resident's paper chart until it was reviewed and signed by the provider. Once the POLST was signed by the provider, staff were expected to place a gold copy of the form in the front of the resident's paper chart and scan it into the resident's EHR. DON identified if a resident was CPR, those wishes would also be identified in the resident's orders and would show up on their EHR. Further, if the resident's POLST identified DNR, the order would read see POLST. DON stated the facility recently completed education to the nursing staff on advanced directives which directed the staff to always look in the front of the paper chart in the event of cardiac arrest to assure the resident's wishes were followed. During a follow-up interview at 2:01 p.m. DON reviewed R20's POLST in R20's paper chart, confirmed the POLST identified CPR and verified it was inaccurate. DON reviewed R20's EHR and confirmed R20's main screen and orders identified CPR and again verified it was inaccurate. DON reviewed R20's current POLST signed [DATE], located in R20's EHR scanned forms which identified DNR and verified it reflected R20's current wishes. During a follow up interview at 2:26 p.m. DON stated POLST orders were completed by nurse manager (NM)-A, MDS coordinator (MDSC)-A, RN-B, or herself. DON indicated she had completed R20's POLST signed on [DATE], with the guardian and had placed it in the provider's file for review and signature. DON verified she was not certain where the paper copy of the POLST was currently located. At 4:00 p.m. DON confirmed R20's current POLST signed [DATE], had been found in the providers folder at the nurses station. DON confirmed R20's POLST orders and paper chart had not been updated after R20's provider had reviewed and signed R20's updated POLST. The facility policy titled Advanced Directives and Rights Regarding Treatment revised ,d+[DATE], identified the resident had the right to refuse treatment and to formulate an advanced directive. Identified if a resident had an advance directive or completed an advanced directive upon admission copies would be obtained and the documents would be consistently maintained in the same section of the resident's medical record and readily retrievable by any facility staff. Indicated the community would periodically review the existing care instructions and whether the resident wishes would change or continue with these instructions. Identified the resident's choices would be documented and communicated to the interdisciplinary team. The IJ was removed on [DATE], at 1:55 p.m. when the facility developed and implemented a systemic removal plan which was verified by interview and document review: -All residents' records were reviewed to ensure the POLST form and electronic medical record were updated to ensure resident's wishes for advance directive and care plan interventions were accurate on [DATE]. -The Advanced Directive policy was reviewed on [DATE]. -Nine RNs and two licensed practical nurses (LPNs) were educated on the policy for advanced directives, obtaining and documenting the POLST to reflect the resident's wishes, on [DATE], to [DATE], as evidenced by the Education Sign in Sheet. -A process was implemented to assure all other nurses completed mandatory education prior the start of their next shift on [DATE], by notification of required mandatory education via phone/text. -During interviews on [DATE], RN-D, NM-A, RN-A, RN-C, and DON, verified they received education regarding policies for advance directives, obtaining and documenting the POLST to reflect the resident's wishes.

Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning, for 1 of 2 residents (R2) reviewed for pressure ulcers. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had diagnoses which included: multiple sclerosis (disease of the central nervous system that affected the flow of information between brain and body) paraplegia (paralysis of lower part of body) and depression. Indicated R2 required extensive assistance with activities of daily living (ADL) and limited assistance for eating. Identified R2 was at risk of pressure ulcers and had one stage two (partial thickness loss of dermis presenting as a shallow open ulcer) and two stage IV (full thickness tissue loss with exposed bone, tendon or muscle) unhealed pressure ulcers, and one stage four pressure ulcer present on admission. Identified R2 utilized a pressure relieving device in chair. R2's MDS lacked documentation R2 was on a turning/repositioning schedule. R2's admission care area assessment (CAA) dated 11/16/22, identified R2 was totally dependent on staff for all ADLs. Identified R2 had a stage four pressure ulcer, required total dependence for bed mobility, required regular scheduled turning, and a special mattress or seat cushion to reduce or relieve pressure. Identified R2's pressure ulcer would be addressed in the care plan. R2's care plan revised 2/27/23, listed various interventions which included staff assistance with bed mobility, dressing, hygiene and transfer with Hoyer (mechanical) lift. Identified R2 currently had pressure ulcers to his right and left gluteal and coccyx areas. Interventions included: low air loss mattress on bed, wound care twice daily and as needed, and encourage repositioning every two hours and as needed while in bed and chair. During an interview on 2/27/23, at 1:05 p.m. R2 indicated he had been in his wheelchair since 8 a.m. and he should have been laid down awhile ago. R2 stated his provider had stated he needed to be repositioned every two hours. R2 indicated he had a large open wound on his buttocks from sitting. On 2/28/23, at 9:16 a.m. R2 was lying on his back in his bed with the head of his bed elevated shaving himself with an electric razor. At 9:34 a.m. R2 continued to lay in his bed in the same position. At 9:42 a.m. R2 continued in his bed in same position while the registered nurse (RN)-A administered his medications. At 9:54 a.m. R2 continued to lay in his bed in the same position while using his IPAD. RN-B entered R2's room for a brief period of time and did not offer to reposition R2. At 11:48 a.m. R2 continued to lay in bed in the same position. R2 confirmed he had not been repositioned since after breakfast around 9:00 a.m. and stated a nursing assistant had recently informed R2 they would be in soon to get him up On 2/28/23, at 11:56 a.m. nursing assistant (NA)-C and NA-D entered R2's room with the Hoyer lift. R2 was dressed in street clothes and had the Hoyer sling beneath him. At 11:59 a.m. NA-C and NA-D transferred R2 from his bed to his wheelchair using the Hoyer lift. NA-C indicated the last time R2 had been repositioned was after breakfast when they assisted him to lay down. NA-C stated they should have repositioned R2 sooner. During continuous observation, R2 was observed in his bed from 9:16 a.m. to 10:59 a.m., two hours and forty three minutes. During a telephone interview on 2/28/23, at 5:01 p.m. NA-E stated she had assisted NA-C to transfer R2 to his wheelchair before breakfast and laid R2 down after breakfast around 9:30 a.m. NA-E indicated NA-C and NA-D had assisted R2 to his wheelchair before lunch. NA-E stated she had not offered or repositioned R2 again until after lunch that day. During an interview on 3/1/23, at 7:17 a.m. NA-D stated she had assisted R2 with repositioning once yesterday before lunch. NA-D indicated she had not offered to reposition R2 any other time yesterday as she was assigned the other area of the building. During an interview on 3/1/23, at 11:36 a.m. RN-A indicated she would expect R2 to be offered to be repositioned every two hours. During an interview on 3/1/23, at 12:00 p.m. nurse manager (NM)-A confirmed R2 was to be offered turning and repositioning every two hours and stated at times R2 would refuse repositioning. NM-A stated when R2 refused to be repositioned every two hours, she would expect staff to inform her, so she could provide education to R2. Additionally, NM-A indicated she would expect staff to inform her if they were behind schedule, so she could assist them with timely repositioning of residents as needed. NM-A stated timely repositioning was important for R2 as R2's pressure ulcers could worsen or become infected if he was not repositioned every two hours. During an interview on 3/1/23, at 2:16 p.m. director of nursing (DON) confirmed R2 had multiple pressure ulcers including stage four pressure ulcers. DON indicated she would expect staff to offer R2 repositioning, and if R2 refused staff would re-approach. DON stated repositioning for R2 was important to prevent worsening of his current pressure ulcers and further skin breakdown. The facility policy titled Pressure Ulcer/Skin Integrity revised 4/22, identified a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and would not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable and would receive necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. The policy identified interventions would be implemented to mitigate the risk of skin breakdown, based on individual risk factors, which may include an individualized turning and repositioning schedule. The policy identified care planning would be comprehensive, resident-centered and would specify interventions to preserve and/or treat skin integrity issues.

Based on observation, interview and document review, the facility failed to communicate in a dignified manner to 1 of 1 residents (R17) reviewed for medication administration. Finding include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 was severely cognitively impaired and had diagnoses which included traumatic brain injury, quadriplegia and seizure disorder. Indicated R17 was totally dependent on staff for all activities of daily living and required nutritional feedings via feeding tube. R17's care plan revised on 2/21/23, indicated R17 preferred to be called by her family name and staff were to reinforce personal connection by using preferred name with each interaction. During observation of medication administration on 2/27/23, at 4:01 p.m. R17 laid in bed covered with a blanket and the head of her bed was elevated. Licensed practical nurse (LPN)-A knocked on the door, entered R17's room with medications in hand and said hello sweet heart, how ya doing today baby. LPN-A proceeded to raise the bed to a working level, sanitized her hands, gloved her hands and administered eye drops into R17's eyes. LPN-A removed her gloves, donned a new pair of gloves and administered R17's other medications while saying ok baby girl. R17 began to cough and LPN-A said you ok baby, ok and continued to administer R17's medications while saying almost done sweet heart. LPN-A continued to administer R17's medication and asked R17, are you having a good day baby. LPN-A finished administering R17's medications, cleaned up her supplies, removed her gloves, sanitized her hands while saying thank you baby and immediately left R17's room On 3/1/23, at 2:16 p.m. nurse manager (NM)-A confirmed the above finding and indicated R17 preferred to be called by her name or nickname. NM-A indicated she would expect staff to follow R17's care plan and it was not acceptable to be using other nicknames or to be talking to residents in a different tone of voice. NM-A stated it was not respectful or dignified to talk to a resident in that manner. On 3/1/23, at 2:37 p.m. the director of nursing (DON) confirmed the above finding and indicated she would expect staff to follow R17's care plan and the facility policy. The DON indicated R17 preferred to be called by her nickname and verifed staff should not be changing their tone of voice or using other nicknames. The DON stated talking to R17 in that manner was not dignified or respectful. On 3/2/23, at 10:20 a.m. family member (FM)-A confirmed R17 would not want to be called anything other than her name or nickname and that it would bother her. Review of facility policy titled, Dignity Quality of Life revised on 10/22, indicated in full recognition of his or her individuality, the facility promoted care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect. Respecting social status by speaking and acting respectfully.

Based on observation, interview and document review, the facility failed to ensure housekeeping services for a clean environment was provided for 1 of 1 resident (R2) who had a soiled wheelchair. Findings Include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had diagnoses which included: multiple sclerosis (disease of the central nervous system that affected the flow of information between brain and body) paraplegia (paralysis of lower part of body) and depression. Identified R2 required extensive assistance with activities of daily living (ADL) and limited assistance for eating. R2's care plan revised 2/27/23, identified R2 had potential for complications with deficits with ADLs related to dependence on staff for cares and transfers and had diagnoses of multiple sclerosis and paraplegia. R2's interventions identified staff assistance in all areas of ADLs with set up assistance for eating. On 2/28/23, at 12:08 p.m. nursing assistant (NA)-C transported R2 in his wheelchair to the dining room. R2's wheelchair cushion on the left side was visibly soiled with multiple white, tan and brown spots varying in size from pin point to one quarter inch in size. On 3/1/23, at 11:26 a.m. R2's wheelchair cushion was visibly soiled on the left side, from the front of the cushion to a few inches from the back. The cushion had white, tan and brown spots varying in size from pin point to 1/4 inch, covering the area. Additionally, the metal areas of his wheelchair and the wheel on the left side had multiple light colored spots, spills, and dust. R2's cushioned foot pedals had multiple crumbs, food and a few spots as well. Registered nurse (RN)-A confirmed R2's wheelchair was visibly soiled, began to wipe R2's wheelchair cushion with a moistened paper towel and picked crumbs and food out of the foot pedals. During an interview on 3/1/23, at 11:36 a.m. RN-A indicated she would expect the nursing assistants to clean R2's wheelchair when it was soiled. RN-A stated R2's wheelchair cushion should have been removed and sent to laundry for cleaning. Additionally, R2's wheelchair should have been cleaned in the facility wheelchair washer. During an interview on 3/1/23, at 12:00 p.m. nurse manager (NM)-A indicated the facility was working on a schedule to assure resident's wheelchairs were cleaned regularly and stated she expected the nursing assistants to wipe off wheelchairs when soiled. During an interview on 3/1/23, at 2:16 p.m. director of nursing (DON) stated she expected staff to keep all residents' wheelchairs clean. DON indicated it was important to keep the wheelchairs clean to maintain a resident' s dignity and for infection prevention purposes. DON stated dependent on the size, the wheelchairs could either be cleaned by the facility wheelchair washer or wiped down by staff. DON indicated wheelchair cushion covers should be removed and laundered, or the cushion replaced when soiled. The facility policy titled Environment-Cleaning Of Equipment revised 10/22, identified the community provided a clean, safe, comfortable, and homelike environment. The policy identified all unit equipment, including wheelchairs, were cleaned on a routine basis. The facility policy titled Wheelchair Cleaning And Routine Maintenance revised 3/22, identified wheelchairs would be maintained in a clean, sanitary and functional condition. The policy identified wheelchairs would be spot cleaned, as needed, to remove any food particles, spilled liquids, or soiling as soon as reasonably possible. The policy identified routine washing of wheelchairs would be completed weekly or more often as needed to remove heavily soiled debris and removable wheelchair cushions would be cleaned and disinfected with an EPA approved disinfectant weekly or as needed.

Based on observation, interview and document review, the facility failed to provide shaving assistance and personal care for 1 of 3 residents (R33) who was dependent on staff to provide personal hygiene. Findings include: R33's quarterly Minimum Data Set (MDS) dated [DATE], indicated R33 was cognitively intact and had diagnoses which included spinal stenosis, muscle weakness and difficulty walking. R33 required limited assistance from staff with bed mobility and transfers Identified R33 required extensive assistance with dressing, toileting, bathing and personal hygiene. R33's care plan revised on 3/1/23, indicated R33 had complications with deficits with activities of daily living (ADL's) related to closed compound fracture of L4 vertebrae to L5, spinal stonosis, weakness and repeated falls. Staff were to assist R33 with personal hygiene. R33's Visual/Bedside Kardex Report dated 3/1/23, indicated R33 required staff assistance with personal hygiene. During observations on 2/27/23, at 1:08 p.m. R33 was seated in his wheel chair in his room and was watching TV. R33's white hair was uncombed, unkept and had white, thick, facial hair all over his entire facial area that was approximately 1/4 of an inch or longer. R33 indicated staff assisted him with dressing and getting ready for the day. - at 2:14 p.m. R33's hair and facial hair remained the same. R33 indicated he wanted the staff to assist him with shaving, while he took his right hand and rubbed his facial area and under his neck area and stated I would like it if they would do it for me. - at 5:01 p.m. R33's hair and facial hair remained the same while he ate supper in his room. During observations on 2/28/23, at 9:51 a.m. R33 was wheeling himself down the hallway in his wheel chair independently using his feet. R33's white hair was uncombed, with roosters sticking up on both sides of his head and his hair was pasted to the back of his head. R33 also had white, thick, facial hair all over his entire facial area that was approximately 1/4 of an inch or longer. - at 9:53 a.m. R33's call light was on and nursing assistant (NA)-C entered his room and R33 was seated on the toilet. NA-C told R33 to turn his call light on when he was done and she left the room shortly after. R33's hair and facial hair remained the same. At 10:01 a.m. R33 put his call light on, NA-C knocked, entered the room and asked R33 if he was going to go to therapy today. NA-C had R33 choose a clean pair of pants, gloved her hands, changed R33's incontinent brief, assisted R33 to a standing position, provided peri cares and pulled up his brief and pants. NA-C assisted R33 to transfer/sit down in his wheel chair, collected the garbage/linen and immediately left R33's room while he thanked her. NA-C did not assist or offer to combed or shave R33's hair. - at 10:43 a.m. R33 was seated in his wheel chair in the therapy room doing exercises with other residents. R33 had white, thick, facial hair all over his entire facial area that were approximately 1/4 of an inch or longer. - at 12:11 p.m. R33's hair and facial hair remained the same while he ate his lunch independently in his room. During observations on 3/1/23, at 8:01 a.m. R33 was seated on the edge of his bed eating his breakfast independently. R33's white hair was uncombed and had roosters sticking up on his head. R33 also had white, thick, facial hair all over his entire facial area that was approximately 1/4 of an inch or longer. R33 indicated he gets a bath every Friday. - at 10:33 a.m. R33's hair and facial hair remained the same while he talked on the phone in his room. During an interview on 3/1/23, at 10:39 a.m. NA-A confirmed R33 needed assistance with personal hygiene, grooming, and shaving. NA-A indicated she had not offered to shave R33 and indicated he usually gets shaved on his bath days. NA-A indicated staff were to make sure R33 personal hygiene was getting done and to assist his as needed. NA-A indicated R33 has never refused cares for her. During an interview on 3/1/23, at 12:06 p.m. NA-B verified R33 receives a bath every Friday and staff shave him on his bath days. NA-C indicated she thought R33 shaved himself everyday by himself. NA-C verified R33 care plan and indicated R33 needed staff assistance for personal hygiene and shaving. NA-C confirmed she had not offered to shave R33 and stated we should be following his care plan. During interview on 3/1/23, at 11:40 a.m. registered nurse (RN)-A confirmed R33's hair was unkept and not combed and he had not been shaven. RN-A indicated R33 required staff assistance with personal hygiene and grooming and indicated the resident usually get shaved on their bath days and as needed. RN-A indicated she would expect staff to make sure the residents are being shaved and well groomed and verifed staff should be following his care plan. During interview on 3/1/23, at 2:47 p.m. the director of nursing (DON) confirmed R33 care plan and indicated R33 required staff assistance with personal hygiene. The DON indicated she would expect staff to offer shaving every day and to comb his hair and to be following R33's care plan. Review of the facility policy titled, Activities of Daily Living revised on 10/22, indicated resident's who are unable to carry out ADL's receives the necessary services to maintain [NAME] nutrition, grooming and personal hygiene.

Based on observation, interview, and document review, the facility failed to ensure care and services, were coordinated with an outside hospice agency for 1 of 1 resident (R9) reviewed for hospice care. Findings include: R9's significant change Minimum Data Set (MDS), dated [DATE], identified R9 had diagnosis which included hypertension (elevated blood pressure) diabetes mellitus (DM) and traumatic brain injury (TBI). Indicated R9 had moderately impaired cognition and required limited assistance with activities of daily living (ADL's) including of bed mobility, toileting, and transfers and received hospice care while a resident of the nursing home. R9's care plan dated 1/6/23, identified R9 had orders for hospice care for a diagnosis of senile degeneration of the brain with comorbidity of malnutrition. A goal was listed which read, (R9) will have management of comfort-physical, psychosocial, spiritual; so that life is neither hastened or prolonged but follows R9's process of concluding life. Review of R9's chart lacked an integrated hospice care plan from the hospice agency. Review of R9's progress notes dated 2/24/23, indicated on 2/22/23, hospice agency had been meeting with hospice provider to discuss pain medications for R9, however the facility had not received orders for the medication until 2/24/23. During an observation on 3/2/23, at 8:55 a.m. a hospice schedule on the inside of R9's door indicated a hospice aide was scheduled to visit twice last week, social worker was scheduled to visit once during the week of 2/6/23, and 2/13/23. The schedule lacked evidence of when a nurse was scheduled to visit R9 in the month of 2/23. A schedule for March 2023 was not posted. During an interview on 3/2/23, at 9:00 a.m. nursing assistant (NA)-A stated she had worked with R9 in the past month, however was not aware R9 was on hospice. NA-A stated she was unsure how hospice communicated with staff to notify them when they would be on site to provide cares for R9. During an interview on 3/2/23, at 9:10 a.m. NA-B stated she had worked with R9 several times in the past month, however was unsure of what, if any services R9's hospice agency was providing for R9. NA-B stated she was not aware of any hospice schedule and only became aware they were coming when they arrived to the facility. During an interview on 3/2/23, at 9:15 a.m. nurse manager (NM)-A stated R9 had been on hospice since 1/6/23. NM-A confirmed the facility had not received R9's hospice care plan from the agency to ensure coordination of care even though the facility had requested one. NM-A stated the hospice agency had not provided a schedule of hospice visits for R9 to the facility. As a result, NM-A stated the facility created and placed a schedule in R9's room of when they anticipated hospice staff would visit. NM-A indicated when hospice staff did visit, they often left without communicating with the facility staff regarding resident status. Additionally, NM-A stated there had been a significant delay in obtaining pain medication for R9 as the hospice agency had not returned the facility's phone calls timely. During an interview on 3/2/23, at 9:29 a.m. director or nursing (DON) stated she was unsure of what the hospice agency's process was for ensuring the facility received a hospice care plan and when a hospice visiting schedule would have been provided to the facility to ensure coordination of care. DON indicated her expectation was the facility would have received a hospice care plan for R9 and a schedule of the hospice visits for R9 in a timely manner. During an interview on 3/2/23, at 9:57 a.m. hospice manager (HM) verified R9 was receiving care from their agency. HM stated the hospice agency usually sent out the frequency of hospice visits to the facilities. NM stated the facility should have received a copy of the hospice care plan as soon as it had been developed. HM further stated his expectation was when a hospice visit had been provided, the hospice staff would have communicated with the nurse or nurse leader at the facility to ensure coordination of care. During an interview on 3/2/23, at 10:22 a.m. hospice social worker (HSW) stated she was unsure if the facility had received a copy of R9's hospice care plan. HSW indicated her expectation was the facility would have received a copy of the hospice care plan and when a nurse made a visit they would have communicated with the nurse at the facility. A facility policy titled Hospice Care revised 3/1/14, indicated when a resident received hospice care the facility's care plan should have been integrated with the hospice agency's plan of care. The policy identified the Hospice company was to collaborate with the facility to provide a schedule of hospice visits and duties.

Based on interview and document review, the facility failed to ensure an allegation of resident to resident abuse was immediately reported to the administrator and immediately reported, no later than two hours, to the State agency (SA) for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and diagnoses which included: cerebral vascular accident (stroke), left sided hemiplegia (paralysis on one side of the body) and anxiety. Identified R1 had no behaviors. Indicated R1 required extensive staff assistance with bed mobility, transfers, toilet use and dressing. Review of R1's facility incident report dated 12/17/22, at 1:30 p.m. identified staff reported R2 followed housekeeper (HK)-A into R1's room and proceeded to remove R1's washcloths from her sink. R1 asked R2 to leave her room and HK-A heard R2 state something she could not understand under her breath. HK-A stated R2 then slapped R1 across the left side of her face. Nursing assistant (NA)-A heard yelling, entered R1's room and assisted R2 back to her room. Review of Incident Report Summary #350502, submitted to the SA on 12/17/22, at 5:44 p.m. identified an allegation of physical abuse occurred when R2 entered R1's room believing it was her own room. R1 yelled at R2 and R2 slapped R1. The report indicated the incident occurred on 12/17/22, at 2:30 p.m. The facility Incident Report Summary #350502, was submitted on 12/17/22, at 5:44 p.m. 4 hours and 14 minutes after the incident occurred. in addition, the report identified the incident occurred on 12/17/22, at 2:30 p.m., though the facility incident report identified it occurred on 12/17/22, at 1:30 p.m. During an interview on 12/27/22, at 2:30 p.m. administrator confirmed the above findings and stated he had been notified by assistant administrator (AA)-A of the allegation of abuse by telephone on 12/17/22, at 4:56 p.m. Administrator indicated he had been informed the incident occurred about an hour earlier and he filed the report to the SA at that time. During a follow up interview at 2:33 p.m. administrator and AA-A stated RN-A did not notify the director of nursing (DON) of the allegation of abuse until after 4 p.m. AA-A and administrator confirmed the allegation was not reported to administrator or SA timely. During an interview on 12/27/22, at 2:23 p.m. registered nurse (RN)-A confirmed the incident occurred on 12/17/22, at 1:30 p.m. and the facility incident report had the correct time of the incident identified. RN-A confirmed she was aware allegations of abuse should be reported as soon as possible. RN-A indicated she did not think about reporting the incident until later and confirmed she reported the allegation of abuse to DON on 12/17/22, at 4:14 p.m. During an interview on 12/27/22, at 3:20 p.m. DON confirmed the allegation of abuse had been reported late. DON indicated she would expect staff to report allegations of abuse timely. The facility policy titled Abuse, Neglect and Exploitation, revised 7/22, identified it was the policy of the facility to take appropriate steps to prevent the occurrence of abuse, neglect and misappropriation of resident property. The policy identified the community was to take appropriate steps to ensure that all alleged violations of federal or state laws which involved mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property (alleged violations) were reported immediately to the administrator of the community. The policy identified if the events that caused the allegation involved abuse or serious bodily injury, it must be reported to the State agency immediately but no later than two hours after forming the suspicion per State and Federal regulation.

Based on interview and document review, the facility failed to implement appropriate foot wear and use of a gait belt during transfers for 1 of 1 residents (R1) reviewed for falls. These findings resulted in an immediate jeopardy (IJ) situation for R1 when R1 fell during a transfer while wearing regular socks and staff were not using a gait belt. R1 required surgical repair of the [CONDITION(S)]. All residents have the potential for serious injury, impairment or death with improper use of transfer devices and improper footwear. The immediate jeopardy began on [DATE], when R1 was transferred without appropriate foot wear and use of a gait belt for safety and had a fall, which resulted in R1 obtaining a serious injury, was transferred to the hospital and it was identified he had an intertrochanteric (hip) fracture. The director of nursing (DON), administrator and the facility consultant were notified of the immediate jeopardy on [DATE], at 7:09 p.m. The immediate jeopardy was removed on [DATE], at 4:13 p.m. when the facility implemented measures to prevent falls for other residents who were at risk for falls, however, noncompliance remained at the lower pattern scope and severity level D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and had diagnoses which included: stroke, malnutrition, depression and anxiety. R1's MDS indicated R1 required extensive assistance with transfers, toileting, dressing and grooming. R1's MDS identified he used a walker and wheelchair, had range of motion impairment on one upper and lower side, was not steady and only able to stabilize with staff assistance. R1's MDS indicated he had no falls and received hospice care. R1's Significant Change in Status Care Area Assessment (CAA) dated [DATE], identified R1 was at risk for falls due to a history of a falls related to [CONDITION(S)] (stroke) and cognitive impairment. R1's CAA identified falls would be addressed on R1's care plan to slow or minimize decline, avoid complications and minimize risk. R1's Fall risk Screening tool dated [DATE], identified R1 had no fall history and had poor safety awareness and noted some cognitive impairment. The tool identified R1 was at risk for falls due to left sided weakness. R1's Fall Risk Screening tool dated identified R1 had one to three falls in three months. R1's tool identified underlying diseases or conditions which included: psychiatric or cognitive conditions, orthopedic/joint/arthritis, neuromuscular/functional loss, [CONDITION(S)] ([CONDITION(S)], stroke) and hip fracture. The tool indicated R1 had recent medication changes due to being on hospice medications for end of life. The tool identified R1 had mobility problems, used assistive devises, and R1 was at risk for falls. R1's care plan dated [DATE], identified R1 was at risk for falls related to gait/balance problems. R1's fall interventions included: ensure R1 was wearing appropriate footwear when ambulating, anti-skid strips placed on floor in R1's bathroom and at bedside, and bed in low position at night. R1's care plan indicated R1 had activities of daily living (ADL) self care performance deficit related to disease process, impaired balance and required 1 staff participation to use toilet. R1's care plan identified R1 required Hoyer (mechanical lift) transfers. R1's incident report titled Fall-Witnessed dated [DATE], at 10:00 p.m. identified staff were in the bathroom with R1 when R1 turned and leaned toward the garbage can to spit, lost his balance and fell , landing on his buttocks and bumped the top of his head on the other door. R1 was initially able to move all extremities. When staff assisted R1 to stand it was noted R1 unable to move his left leg and complained of pain in his hip. R1 was assisted into a wheelchair. Injuries observed at the time of the incident included an abrasion to the top of R1's scalp and fracture of left trochanter (hip). Other information listed on the report identified R1 had regular stockings on his feet instead of the gripper socks. R1's Interdisciplinary Team (IDT) Post Fall Review dated [DATE], identified R1 fell on [DATE], at 10:00 p.m. The review identified R1 had turned and was bending over the garbage to spit, lost his balance and fell . R1's current interventions included dycem (non-slip material) in chair and gripper socks on feet. R1's review identified R1 did not have gripper socks on at the time of the fall. On [DATE], at 1:23 p.m. during a telephone interview, nursing assistant (NA)-A confirmed R1 was wearing regular socks at the time of the incident instead of the gripper socks. NA-A confirmed he did not have a hold of the gait belt when R1 fell . NA-A stated when NA-A assisted R1 off of the toilet, R1 leaned over to spit as he normally did, lost his balance and fell backwards. NA-A stated he let go of the gait belt as R1 bent over to spit as he felt there was not enough room to hang on to the gait belt. NA-A indicated no follow up education had been provided by the facility. On [DATE], at 1:28 p.m. during a telephone interview, licensed practical nurse (LPN)-A stated she had completed the initial assessment after R1's fall. LPN-A confirmed R1 wore regular socks instead of the gripper socks when the fall occurred. Additionally, LPN-A stated NA-A informed her he had let go of R1's gait belt in the bathroom before R1 fell . LPN-A stated she had received no education regarding fall prevention following the incident. On [DATE], at 1:35 p.m. NA-C indicated R1 required assistance of one staff with a gait belt and walker and at times would require the use of the PAL or Hoyer lift for transfers. NA-C stated she always held onto R1's gait belt when he stood, transferred or walked, and indicated R1 would always turn the same way each time he was transferred off the toilet. NA-C stated she had not received education following R1's incident. On [DATE], at 2:59 p.m. NA-B stated R1 required assistance of one staff and a gait belt for transfers. NA-B indicated she would always hold the gait belt when R1 was transferred. NA-B stated R1 at times required a PAL lift when R1 was very tired. NA-B indicated she had not received any education after R1's fall. On [DATE], at 3:30 p.m. registered nurse (RN)-A indicated she always utilized a walker and gait belt when assisting R1 to the bathroom. RN-A stated R1 had a shuffling gait and would always turn to spit in the garbage can. RN-A indicated staff were aware R1 would trip up during the transfer, however R1 never fell in the bathroom prior to the [DATE], fall. RN-A stated R1 became unsteady when he would turn to spit. RN-A confirmed the facility had not provided education to staff following R1's fall. On [DATE], at 3:40 p.m. clinical manager (CM)-A stated prior to R1's [DATE], fall, R1 required assistance of one staff while utilizing a walker and gait belt for transfers and walking. CM-A indicated R1 had a shuffling gait, was unsteady and staff were expected to always use a gait belt and walker when transferring him. CM-A stated staff were expected to utilize the gait belt when transferring R1 off of the toilet as R1 would routinely lean and spit into the garbage can prior to exiting the bathroom. Review of R1's progress notes from [DATE], to [DATE], identified the following: -[DATE], at 10:30 p.m. alerted by nursing assistant (NA), R1 found on floor in bathroom, feet outside bathroom door and head next to opposite door. NA stated R1 turned to leave bathroom, bent over garbage to spit, lost his balance and fell hard on his bottom and bumped his head on opposite door. Initially, R1 was able to move all 4 extremities while lying down. Once staff assisted R1 off the floor, it was noted R1 was unable to move his leg and complained of pain. Hospice and family were contacted and agreed to transfer R1 to emergency room for x-rays and pain management. R1 transferred to emergency room per ambulance. -[DATE], at 2:30 a.m. facility staff received a call from the hospital, R1 had a [CONDITION(S)] and the plan was for surgery tomorrow or the next day. -[DATE], at 4:42 p.m. R1 transferred from hospital back to the facility. R1 had right hip surgery on [DATE], after a witnessed fall at facility. R1 was admitted to hospice. -[DATE], at 9:20 a.m. R1 passed away peacefully about 9:05 a.m. with family present. Hospice and the funeral home were notified and the body was removed. R1's Emergency Department (ED) Provider Notes dated [DATE], identified R1 was admitted to the emergency room with complaint of left hip pain after a fall. The note identified R1 had a small laceration to his head and some discomfort there as well. The ED course identified R1's small laceration to the back of his head was cleansed thoroughly and adhesive was placed over the wound for closure. R1 was on Hospice and R1 revoked his hospice care at the time. R1's X-ray of the hip demonstrated an intertrochanteric (hip) fracture. R1's Hospital Discharge Summary dated [DATE], identified R1 was admitted from the facility where he was on hospice services. R1 had fallen with a left hip fracture. R1 was admitted and hospice was discontinued to surgically repair the hip for comfort measures. R1 was slow to mobilize with therapy and did not return to his pre-surgical condition mentally. R1 had some improvement, however, was noted to be choking on fluids yesterday, discussion held with family and agreed to have R1 transferred back to the facility on hospice. Hospice consulted with plans to admit R1 later today at the facility. R1's Orthopedic Surgery Discharge Summary dated [DATE], identified R1 was admitted to hospital on [DATE], for a principle and pre-operative diagnoses of closed left intertrochanteric (hip) fracture. R1 had a surgical repair which consisted of a left trochanteric fixation and nailing. R1's Documentation Of Death form, undated, identified R1 died on [DATE], of [CONDITION(S)], and presumed aspiration pneumonia. The form identified other significant concerns contributing to death was the fall resulting in hip fracture [DATE], and R1 underwent surgery on [DATE]. On [DATE], at 3:33 p.m. administrator indicated after R1's fall, the nurse assessed him and noted R1 had no pain, however, after a short time R1 developed pain and was transferred to the hospital. The facility received notification R1 had a fracture and had chosen surgery. Administrator indicated when R1 was readmitted to the facility, R1 was placed back on hospice services. Administrator stated he completed the five day investigation after R1's fall which included interviewing NA-A who was present during R1's fall, LPN-A who assessed R1 after his fall and CM-A. Administrator confirmed he had not been aware R1's fall prevention interventions were not being followed, or any concerns with how NA assisted R1 in the bathroom or during his transfer, which resulted in R1's fall. Administrator confirmed he had not been aware it was identified on R1's IDT Post Fall Review R1 had been wearing regular socks instead of the gripper socks. Administrator confirmed the facility had not provided any education to the staff following R1's fall, as he believed at the time NA-A had followed the facility procedures. The facility policy titled Accidents/Falls-HDRG revised ,d+[DATE], identified the facility strived to promote safety, dignity, and overall quality of life for its residents by providing an environment that was free from any hazards for which the facility had control and by providing appropriate supervision and interventions to prevent avoidable accidents. The policy further identified a care plan for fall risk would be developed and communicated to all appropriate staff. The policy identified that each incident/accident or fall would be investigated and/or assessed to determine the cause of the episode to prevent any further injury and the interdisciplinary team would review all incident/accident reports whenever possible. The facility policy titled Gait/Transfer Belt, revised ,d+[DATE], identified gait/transfer belts may be used to prevent injury to employees and the resident when transferring the resident. The policy procedures included applying the belt around the resident's waist over his/her clothing, allowing enough room between the belt and his/her clothing for a flat hand to be inserted and after the transfer removed the belt. The IJ which began on [DATE], was removed on [DATE], when the facility successfully implemented a removal plan which included: review of the policies for accidents and incidents, development of person-centered care plans, and gait belt for transfers, review of current residents' care plans and Kardex to determine fall interventions were appropriate and accurate, with observations made to assure appropriate interventions were in place. The facility provided education to nursing staff on proper use of transfer belts, transfers, following the care plan for interventions to prevent falls, and use of Kardex for location of fall interventions. The facility performed competency testing of staff for use of transfer belts as well. The facility provided education to the staffing director to ensure nursing staff were checked off on education list and to notify the DON/designee to educate staff prior to working their next shift. On [DATE], between 1:40 p.m. to 4:00 p.m. interviews with staffing director, nursing staff and management verified training on transfer belts, transfers, fall interventions and Kardex was completed, as well as all residents were reviewed to assure fall interventions were in place and accurate. The facility had a plan in place and check off system to assure all staff would be educated prior to working their next shift.

Based on observation, interview and document review, the facility failed to complete comprehensive, accurate and ongoing nutritional assessments for 4 of 5 residents (R20, R24, R31, R30) who had experienced significant weight loss. R20 sustained actual harm when the facility failed to identify, assess and implement interventions in a timely manner to prevent continued weight loss while receiving all nutrition via tube feeding. R20 R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 had severe cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's MDS indicated she required extensive assistance with dressing, personal hygiene and bed mobility and had a feeding tube with 51% or more of total calories received through the tube feeding. The MDS identified R20 had no or unknown weight loss and her current weight was 168. R20's Care Area Assessment (CAA) dated 5/10/21, identified R20 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The CAA indicated R20's nutritional status-functional status would be addressed in the care plan to avoid complications, maintain current level of functioning and minimize risks and no dietary referral was warranted. R20's care plan, revised 7/27/21, identified R20 had a self-care performance deficit related to TBI and was totally dependent upon staff for repositioning/turning, bathing, dressing, and personal hygiene. R20's care plan indicated R20 had the potential for alteration in nutritional status and was at risk for dehydration related to the need for a tube feeding to meet nutritional needs secondary to her inability to safely swallow. R20's care plan interventions included: weights weekly, dietary consults as deemed appropriate. On 9/22/21, at 7:09 a.m. R20 was in her bed, with the head of bed elevated. R20's tube feeding of [MEDICATION(S)] was running at 60 ml (milliliter) /hour. Review of R20's weights from 8/12/21, to 9/16/21, identified the following: -8/12/21, 172.5 pounds -8/19/21, 165.8 pounds -8/26/21, 166.4 pounds -9/1/21, 170.4 pounds -9/9/21, 165.9 pounds -9/16/21, 163.2 pounds -9/23/21, 164.3 pounds Review of R20's weights from 8/12/21, to 9/16/21, identified a significant weight loss of 5.39 % in one month. R20's annual dietary assessment dated [DATE], identified a weight of 170.3 pounds, BMI (body mass index) 30.2 indicated obesity, however weight was stable. R20 was NPO and the had tube feeding of [MEDICATION(S)] 1.2 at 60 ml (milliliter)/hour X 15 hours. The feeding provided 1080 Kcal (kilocalorie), approximately 50 grams protein and 900 ml fluid. R20 received 200 ml flushes every 4 hours. The assessment indicated R20 remained very stable therefore no changes were recommended at the time. The plan was to continue to monitor. R20's medical record (MR) lacked a comprehensive dietary assessment completed after R20 had a significant weight loss from 8/12/21, to 9/16/21. Additionally, R20's comprehensive nutritional assessment completed 4/9/21, lacked a detailed review of R20 including R20's medications and medical diagnoses. Review of R20's signed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's orders also included 300 cc of water flush six times a day for hydration. Review of R20's progress notes from 8/12/21, to 9/23/21, identified the following; -8/12/21, 4:04 a.m. R20 returned from emergency department, on antibiotic. -8/15/21, R20 had abdomen distention, with sluggish bowel sounds and no signs of discomfort. R20 had difficulty with tube feeding, staff held the tube feeding and CNP notified. -8/16/21, discussion had with CNP and R20 was transferred to the local emergency room (ER) for evaluation of gastric tube site, patency and urinary issues. -8/17/21, R20 returned from ER and R20 was seen by provider. R20's feeding was changed to [MEDICATION(S)] 65 cc per hour for 5 hours, three times a day (TID) for a total of 900 cc in 24 hours and antibiotic orders were to continue. -8/20/21, dietary note-R20 appeared to be tolerating the new tube feeding (TF) regimen running at 60 ml /hour x 5 hours, being off for 3 hours, repeated 3 times a day. Since it was going well, staff were not sure if it should have been changed. Nursing planned to speak with NP to see if adjustments should have been made with the water flushes so R20 had few interruptions to her day. The note indicated the plan was to continue to monitor. -8/27/21, R20 seen by provider for pre-op (pre-operation) consult history and physical assessment. No new orders were received. -9/1/21, 7:45 a.m. transferred to the local hospital for a procedure today. -9/8/21, R20 seen by provider. -9/18/21, Consult with NP, family and physician regarding nephrostomy tubes. R20's progress notes lacked identification of R20's significant weight loss. The notes lacked documentation the dietician and provider were notified of R20's significant weight loss. Additionally, the notes lacked documentation of a nutritional comprehensive assessment to identify the cause of the significant weight loss or any interventions to assist in preventing further weight loss. R20's Primary Care Physician (PCP)-A progress note dated 7/29/21, identified R20 had tube feedings which were functioning well. R20 remained on [MEDICATION(S)] for her tube feedings which ran at 60 cc/hr for 15 hours in a day. The note identified R20's weight was down to 168.3, and indicated her weight was 172.9 a month ago. The note indicated the plan was to continue with comfort cares and no new orders were written. R20's certified nurse practitioner (CNP)-B progress note dated 8/12/21, included review of an ER visit related to a possible ileus (inability of intestine to contract and work normally, which can lead to bowel obstruction). The note indicated R20's weight was 171 pounds and 4 ounces. The note identified R20 had constipation and the plan was to give R20 a Fleets enema today. The note indicated R20 was to start on [MEDICATION(S)] daily and staff were to notify the provider if no bowel movement (BM) by tomorrow or signs or symptoms of distress developed. R20's CNP-A progress note dated 8/17/21, identified R20's weight readings from the last encounter, 8/12/21, 172 pounds 5 ounces. The note identified a plan to address issues with the tube feeding, suggest splitting up feeding times as follows (5 hours on, 3 hours off) to continue same rate as currently ordered, notify provider if patient was not able to tolerate feedings. R20's CNP-A progress note from 9/8/21, noted placement of bilateral nephrostomy tube and [CONDITION(S)] stent on 9/1/21. Prior to hospitalization , R20 had issues with G-tube, changes were made in timing of feedings as well as cares, that seemed to improve symptoms. Weight reading from last 1 encounter 9/8/21, 170 pounds 4 ounces. R20's provider progress notes lacked identification or assessment of R20's significant weight loss and a plan to prevent further weight loss. On 9/22/21, at 11:28 a.m. licensed practical nurse (LPN)-A indicated the facility weighed R20 once a week. LPN-A stated R20 had recent changes made to her feeding tube administration which consisted of 300 cc of the feeding over 5 hours, stop for 3 hours and start it up again. LPN-A indicated R20 had experienced some distension with feeding running continuously and as a result was changed however R20 continued to receive the same amount of feeding solution. LPN-A stated the last weight she entered in the MR for R20 was 165 however she could not recall if she notified anyone of the significant weight loss. LPN-A indicated the nurse manager was responsible for notifying the PCP when rounds were made of any changes in condition. On 9/22/21, at 11:20 a.m. dietary manager (DM)-A stated she was new to the position and had been in the position only a few weeks. DM-A stated weights were monitored by nursing staff, and they were expected to notify her if there was a weight loss. DM-A confirmed she had not been notified of any concerns of weight loss for any of the residents in the facility, including R20 who had experienced a significant weight loss. On 9/22/21, at 11:46 a.m. clinical manager (CM)-A with CM-B in the room confirmed R20 had change in condition in the last month, and her provider had evaluated her and made some order changes. CM-A stated R20's abdomen had become distended, she was hospitalized and adjustments to her tube feeding schedule had been made. CM-A indicated R20 had been stable, until 8/13/21, when she had been transferred to the ER. CM-A confirmed there was no documentation in R20's MR which revealed R20's PCP or CNP had been notified of her significant weight loss. CM-A confirmed R20 was flagged in her MR for weight loss and indicated they had discussed R20's weight loss at their facility risk meeting. On 9/22/21, at 12:15 p.m. during a phone interview registered dietician (RD)-A indicated she was notified R20's tube feeding had been changed to shorter feeding times when she was present in the facility on 8/20/21. RD-A stated she was not certain if she had checked R20's weight at that time. RD-A reviewed weights on R20's and confirmed R20 experienced a significant weight loss of 5.78% from 8/12/21, to 9/16/21. RD-A confirmed she had not been notified or R20's significant weight loss over the past month. RD-A stated she expected the facility to notify her of R20's weight loss and especially when it was a significant one. On 9/22/21, at 2:13 p.m. during a phone interview, certified nurse practitioner (CNP)-A confirmed R20 recently had some issues with her gastric tube, possibly some constipation and had been seen in the ER. CNP-A indicated R20 had been experienced discomfort when staff flushed her tube feeding and as a result they made adjustments to the timing of R20's feeding. CNP-A stated she expected weights to be monitored regularly. CNP-A confirmed she had not been notified of R20's significant weight loss. After review of R20's weights, CNP-A confirmed R20 had experienced a significant weight loss in the past month and she would have expected the facility to notify her and the dietician of the weight loss. CNP-A indicated sometimes when a resident had an acute illness while they were on a tube feeding, their body's metabolic demands increased and calorie adjustments could have been made to assist in preventing further weight loss. On 9/23/21, at 12:46 p.m. director of nursing (DON) confirmed she was aware R20 had experienced a significant weight loss. DON stated R20's weight loss had been discussed at the facility risk meeting however the dietician had not been present at the meeting. DON confirmed R20's primary care provider and the dietician were not notified of R20's significant weight loss. On 9/24/21, at 9:18 a.m. during a phone interview R20's primary care physician (PCP)-A confirmed she had not been notified of R20's weight loss until yesterday, 9/23/21. PCP-A confirmed R20 had a significant weight loss and would have expected to be notified earlier. Additionally, PCP-A confirmed she would have expected the facility to notify the dietician of R20's significant weight loss. The form provided by the facility titled, Facility At Risk Meeting dated 9/9/21, identified R20's weight 166-163 pounds, completed procedures for kidney stones, baseline weight was 170 pounds, feeding changed around 8/16/21, and the plan was to continue to monitor. The facility policy titled Weight Loss reviewed 5/20, identified the facility ensured residents who entered the facility would not fall below their ideal weight range, unless the weight loss was viewed as unavoidable. The policy/procedures included: the residents would be assessed for at risk dietary council completed and suggestions implemented, and dietary or designee, and nurse's notes were to address weight loss issues. The facility policy titled Nutrition (General) dated 4/1/08, identified the facility maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical conditions demonstrated that was not possible. The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 dated 10/2019, identified Section K: Swallowing/Nutritional Status to be completed with an intent to assess the many conditions that could affect the resident's ability to maintain adequate nutrition and hydration. Under K0300: Weight Loss Planning for Care: - Weight loss may be an important indicator of a change in the resident's health status or environment. - If significant weight loss is noted, the interdisciplinary team should review for possible causes of changed intake, changed caloric need, change in medication (e.g. diuretics), or changed fluid volume status. - Weight loss should be monitored on a continuing basis; weight loss should be assessed and care planned at the time of detection and not delayed until the next MDS assessment. R24 R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had moderate impaired cognition and required extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use, personal hygiene, and was independent with eating. The MDS indicated R24's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R24's weight was 103 pounds (lbs.). R24's MDS did not identify any weight loss. R24's admission care area assessment (CAA) dated 8/8/21, identified R24 was on a regular diet, thin liquids, soft and bite size pieces. The CAA identified staff assisted with meal set up. R24 received house protein drinks between meals. The CAA revealed R24's BMI (body mass index) was 18.2436 (normal weight 18.5 to 24.9). R24's care plan dated 8/3/21, identified R24 was at risk for actual or potential for complications with nutrition due to (d/t) poor intake. R24's care plan interventions included: preferred small portions, record weights at a minimum of monthly or per medical doctor/registered dietitian nutritionist (MD/RDN). The care plan indicated R24 was allowed to eat/drink as desired/accepted/tolerated. The care plan instructed staff to offer/provide/encourage increased calorie and protein containing foods with meals. Assist of one with cutting up foods and cueing. The care plan identified R24 required assistance with activities of daily living (ADL's) and required assistance of one staff with eating. One intervention on R24's care plan had been identified and created on 9/12/21, supervised meals. R24's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's treatment administration record (TAR) for August 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR revealed R24 had been administered the supplement, however the TAR lacked the amount R24 accepted. R24's TAR for September 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR revealed a check mark which identified R24 had been administered the supplement, however the TAR lacked the amount R24 accepted. R24's Kardex Report (nursing assistant care guide) dated 9/24/21, identified R24 required assist of one with cutting up of foods, eating and cueing. R24's current electronic weight summary from 8/11/21, to 9/22/21, identified the following weights in pounds (lbs): 8/11/21 103.6 lbs. 8/15/21 90.6 lbs. 8/16/21 94.8 lbs. 8/25/21 90 lbs. Which indicated R24 had lost 12.62 % of her body weight since 8/11/21. 9/22/21 91.2 lbs. On 08/11/2021, R24 weighed 103.6 lbs. and on 08/25/2021, the R24 weighed 90 lbs. which was a 13.13 % significant weight loss. The summary lacked any weights completed from 8/26/21, until 9/22/21. Review of Dietary progress note dated 8/25/21, completed by Dietary Culinary Director (DCD)-A identified R24 preferred a three compartment plate (did not like her food touching), received a mechanical diet (meat and vegetables), and required all other food to be cut up (toast, sandwiches). The note did not address R24's required nutritional needs or her 13% weight loss in 14 days. R24's medical record (MR) lacked a comprehensive nutritional assessment, which included minimal caloric requirements/nutritional needs to maintain weight, review of medications, medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R24's form titled meal intake dated from 8/27/21 through 9/24/21, revealed R24's intakes varied from 25-75% and identified inconsistent documentation of R24's intakes as follows: - no meal intakes were documented on six days, which left 21 of 27 days R24's intakes were documented. - one of three meal intakes were documented on 13 of the 21 days intakes were documented. - two of three meal intakes were documented on 4 of the 24 days intakes were documented Review of R24's provider progress notes from 8/4/21, to 9/15/21, revealed the following: - 8/4/21, certified nurse practitioner (CNP)-C's physical exam identified R24's lower extremities were without [CONDITION(S)]. [CONDITION(S)] (repetitive muscle contractions) and fine tremor were noted and were not new for R24. -8/17/21, primary care physician (PCP)-B saw R24 during nursing home rounds and completed a test on R24 which suggested dementia. The note identified R24 required cues for eating. The note indicated R24 had no lower extremity [CONDITION(S)] and continued to have chronic conditions of MS with [CONDITION(S)] and a chronic fine tremor was noted. The note identified R24 was stable. - 9/8/21, CNP-C identified R24's family had reported to nursing they had noticed subtle cognitive changes. CNP-C's physical exam of R24 identified her lower extremities were without [CONDITION(S)] and R24 continued to have a tremor mostly of her head, and rigidity. CNP-C questioned if R24 had [CONDITION(S)]. -9/15/21, CNP-C identified R24 had shown improvement in rigidity and voice projection, and with the fine tremor noted in resting hands. CNP-C's physical exam of R24 identified her lower extremities were without [CONDITION(S)]. R24's provider notes lacked identification of R24's significant weight loss. Review of R24's progress notes from 8/2/21, through 9/23/21, identified: -8/4/21, at 1:18 p.m. revealed R24 was seen by her provider and was ordered a supplement twice daily. The note lacked a rationale or identified a reason R24 was ordered the supplement. resident was seen by provider CNP-C, assessment completed, labs, medications and POLST (provider orders for life-sustaining treatment) reviewed. Orders received for labs and house supplements twice a day (BID). -8/24/21, note indicated R24 refused to go to the dining room for breakfast, had a tray in her room and took her medications with a supplement. The note did not identify whether R24 had eaten her breakfast. -8/25/21, at 10:16 a.m. revealed R24 weight that day was 90.0 pounds, nurse manager was notified and required to increase supplement to three times daily, currently ordered twice daily. -9/12/21, note revealed R24's plan of care had been updated to reflect R24's needs to supervision with meals. The note lacked any indication or rationale for R24 required supervision with eating. The note lacked any mention of R24's weight loss. R24's progress notes lacked any documentation identifying or assessing R24's significant weight loss. During an observation on 9/22/21, from 12:00 p.m. to 1:00 p.m. R24 sat in the dining room at a table. At 12:10 p.m. R24's tray of cut up hot dog, beans, located on a divided plate, a bag of unopened chips, and a glass of apple juice were placed on the table in front of her. R24 fed herself slowly approximately 25% of her meal (mostly meat) and drank ½ cup of her apple juice. At 1:00 p.m. R24 verbalized she had finished eating and an unidentified staff pushed her in the wheelchair out of the dining room. No cueing or assistance had been provided or offered to R24 during this observation. During an observation on 9/23/21, at 8:28 a.m. R24 sat in the dining room at a table and fed herself breakfast. R24 had scrambled eggs, oatmeal, and toast on her divided plate, a glass of apple juice with a cover with a straw in it, and a coffee cup with liquid in it. Nursing assistant (NA)-B sat next to R24, occasionally gave her drinks of apple juice and asked R24 if she needed assistance. R24 drank two sips of apple juice and ate only her scrambled eggs slowly. On 9/23/21, at 8:44 a.m. resident requested to be brought back to her room. An unidentified staff came over to R24, removed her clothing protector and wheeled her out of the dining room in her wheelchair. During an observation on 9/23/21, at 12:21 p.m. R24 sat in the dining room at the table along with two other residents. NA-C sat between R24 and R8 at the table. At 12:29 p.m. NA-C placed a tray in front of [NAME] with a plate on it covered up and stated she would be back to help her. At 12:33 p.m. NA-C assisted R8 with her meal. R24 fed herself slowly with a spoon from a divided plate that contained carrots, potatoes, and pureed meat. R24 ate 10 % of her meal and drank one half of her apple juice. No cueing or assistance had been provided or offered to R24 during this observation. At 12:50 p.m. R24 had been taken out of the dining room in her wheel chair by NA-C. During an interview on 9/21/21, at 9:39 a.m. R24 identified she had a hard time feeding herself and it had progressively gotten worse. R24 stated her hands shook from [CONDITION(S)]. R24 indicated she was aware she had experienced weight loss, was not aware why she had lost weight and stated it concerned her. During an interview on 9/22/21, at 10:28 a.m. registered nurse (RN)-A stated R24 received 4 to 8 ounces (oz) of ensure a day, however her intake of the supplements had recently declined. R24 had a new [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated her ability to eat had improved since the new medication had been started about two weeks ago. RN-A indicated she did not know why R24 had experienced a significant weight loss. During an interview on 9/23/21, at 9:17 a.m. RN-B confirmed she had not been aware of R24's significant weight loss. RN-B indicated R24 needed encouragement to eat and her intake varied from day to day. RN-B stated the nursing assistants weighed the residents and reported the weights to the nurse. During an interview on 9/23/21, at 9:22 a.m. NA-E stated R24 was usually independent with eating, though had recently required supervision and physical assistance at times with eating due to her hands shaking. NA-E indicated R24 usually ate approximately 50% of her meals. During an interview on 9/23/21, at 2:57 p.m. clinical manager (CM)-A stated a registered dietician was expected to complete the comprehensive nutrition assessments on all residents and confirmed the assessment had not been completed on R24. CM-A verified no weights had been completed on R24 from 8/26/21, to 9/22/21, and since she had experienced a significant weight loss, further weights and monitoring should have been completed. CM-A confirmed R24 had experienced a significant weight loss. During a phone interview on 9/23/21, at 11:45 a.m. certified nurse practitioner (CNP)-C confirmed R24's weight had dropped from 103 lbs. to 90 lbs. since her admission and verified it was a significant weight loss. CNP-C stated the weight loss was at least a 10% weight loss and indicated she was not aware of R24's typical weight was nor was she aware of what R24's desired weight was. During a phone interview on 9/23/21, at 4:25 p.m. registered dietician (RD)-A stated she normally received emails when a resident had been admitted or discharged . RD-A stated she had not received an email when R24 was admitted . RD-A indicated she ran the admission/discharge report and R24's name was not included in the report. RD-A confirmed she was not aware of R24's significant weight loss and had not completed a comprehensive nutritional assessment. On 09/24/21 9:37 a.m. a phone call was made to this R24's primary care physician (PCP)-B, message left. During a phone interview on 9/24/21, at 9:44 a.m. a family member (FM)-C stated R24's appetite had decreased and she consumed maybe a quarter of her meals with encouragement provided. FM-C verified R24's normal weight had been approximately 120 lbs. FM-C indicated he did not understand why R24 had lost weight and had been very concerned about the weight loss. FM-C confirmed he had not been notified of R24's weight loss until 9/23/21. During an interview on 9/24/21, at 12:13 p.m. director of nursing (DON) confirmed R24 had experienced a significant weight loss and had not been comprehensively assessed by the facility dietician or dietary manager. The DON stated she would have expected R24 to be assessed following the significant weight loss. R31 R31's quarterly MDS dated [DATE], identified R31 had moderately impaired cognition and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R31 required supervision with eating, weight 125 lbs., an identified weight loss of 5% or more in the last month, and was not on a weight loss regime. R31's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R31's care plan revised 8/28/21, identified R31 had a potential for alteration in nutritional status related to (r/t) left [CONDITION(S)], disorientation, and stroke symptoms. The care plan interventions included: heart healthy diet, 2 gm sodium diet; regular textures, thin liquids. The care plan instructed staff to monitor intakes of food and fluids at meals, offer snacks between meals per facility policy, supplements per MD order, provide assistance with meals as needed. Diet consults as deemed appropriate. Document meal refusals. Resident prefers to eat all meals in the dining room, occasionally requests a meal tray in her room. R31's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's weights from 3/14/21, through 9/1/21 identified: 3/14/21, 145.6 Lbs. On 03/14/2021, the R31 weighed 145.6 lbs. On 09/01/2021, R31 weighed 121 pounds which is a -16.90 % Loss. 3/17/21, 145.6 Lbs 3/24/21, 142.6 Lbs 3/31/21, 142.0 Lbs 4/7/21, 144.4 Lbs 4/14/21, 141.8 Lbs 4/21/21, 142.6 Lbs 4/28/21, 141.4 Lbs 5/12/21, 139.2 Lbs 5/19/21, 139.2 Lbs 5/26/21, 135.6 Lbs 6/4/21, 140.0 Lbs 6/16/21, 134.8 Lbs 6/23/21, 132.6 Lbs 6/4/21, 140.0 Lbs 6/16/21, 134.8 Lbs 6/23/21, 132.6 Lbs 6/30/21, 130.2 Lbs 7/14/21, 132.0 Lbs 7/28/21, 129.2 Lbs On 07/28/2021, the R31 weighed 129.3 lbs. On 09/01/2021, R31 weighed 121 pounds which is a -6.42 % Loss. 8/11/21, 125.0 Lbs 8/25/21, 124.8 Lbs 9/1/21, 121.0 Lbs R31's form titled Meal Intake dated from 5/1/21, through 9/19/21, identified the following: -5/1/21, through 5/31/21, ate 26 to 100 % of meals-6/1/21, through 6/30/21, ate 51 to 100% of meals -7/1/21, through 7/31/21, ate 26 to 100% of meals -8/1/21, through 8/31/21, ate 26 to 100% of meals -9/1/21, through 9/19/21, ate 0 to 100% of meals The forms lacked any intakes for the following dates: 8/6/21, 8/15/21, 9/3/21, and 9/13/21. Review of R31's progress notes from 3/10/21, through 9/14/21, progress notes revealed the following: -5/4/21, at 1:35 p.m. slept in this morning (AM) due to headache. Refused breakfast when offered. Went to lunch room for noon meal. -6/28/21, at 1:30 p.m. resident refused to get up this shift, stated she had a headache and didn't want to get up. R31 refused to eat meals. Has been taking liquids. -8/20/21, dietary progress note: revealed the author had spoken to R31 about her significant weight loss, and identified her current weight was 125 lbs. The note revealed R31 had lost 2 lbs in the past six months. Staff felt her weight loss maybe attributed to her starting to smoke again. R31 stated she was not at all concerned about her weight. Stated her appetite was good. Meal intake was 50%. R31 adamantly declined an oral supplement. Per her wishes, no changes were recommended. During an observation 9/22/21, at 9:00 a.m. R31 sat in her room, fed herself, and ate 100% of her breakfast of an omelette, toast, and coffee. During an observation on 9/23/21, at 8:49 a.m. R31 sat in her room, fed herself, and ate 100% of her breakfast which consisted of: scrambled eggs, toast with peanut butter, and coffee. During an interview on 9/21/21, at 10:49 a.m. R31 stated her appetite had declined. R31 indicated she had lost some weight however she was not sure how much weight she had lost. During an interview on 9/22/21, at 10:28 a.m. RN-A stated R31 did not like taking supplements and recently quit smoking. RN-A indicated R31 ate her meals in the dining room and the staff kept track of what she ate and her weights. During an interview on 9/23/21, at 9:11 a.m. NA-A stated R31 had skipped meals. NA-A verified she had not been aware of R31's weight loss and hoped the nurses would have followed up on it and/or provided her with ensure. During an interview on 9/23/21, at 2:57 p.m. CM-A confirmed a comprehensive nutrition assessment had not been completed on R31. During an interview on 9/23/21, at 4:25 p.m. RD-A stated R31 had been admitted before she became the facility dietician and confirmed she had not completed a comprehensive nutrition assessment on R31. RD-A verified she had not received any emails or notifications from the facility notifying her of R31's weight loss. During an interview on 9/24/21, at 12:13 p.m. DON stated it was expected the RD completed a comprehensive nutritional assessment on each new admission. DON confirmed a comprehensive nutrition assessment had not been completed on R31. Facility policy titled Weight loss reviewed 5/2020, identified the facility ensures that residents who enter the facility will not fall below their ideal body weight range, unless the weight loss is viewed as unavoidable. Procedure: those resident's at risk noted on care plan with individual interventions. Charts contain current weight, ideal body weight, and lab data regarding nutritional issues. Dietary consult completed and suggestions implemented. MD aware of as risk with documentation in clinical record. Care plans updated as appropriate. Dietary or designee, and nurse's notes address weight loss issues. R30 R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R30 had moderate cognitive impairment and was totally dependent for all activities of daily living (ADL's) which included eating, transfers, bed mobility and locomotion. The MDS identified R30's weight at the time of the assessment was 91 pounds (lbs), had no loss of food or fluids when eating/dri

Based on observation, interview and document review the facility failed to provide ambulation services to prevent loss of function for 1 of 2 residents (R22) reviewed who required assistance with ambulation. R22 was not provided assistance with ambulation and was not re-assessed upon a decline in ambulation. R22's decline in ambulation resulted in actual harm. In addition the facility failed to provide range of motion services to prevent potential decrease in range of motion (ROM) for 3 of 3 residents (R44, R37, R27) reviewed whom required range of motion for restorative nursing exercises. Findings include: R22's admission Minimum Data Set ((MDS) dated [DATE], identified R22 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS identified R22 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers and ambulation. The MDS indicated R22 used a walker and wheelchair with assistance for mobility, was unable to maintain his balance without physical assistance, and had no functional limitation of range of motion of any extremities. Further, the MDS indicated R22 was receiving both occupational and physical therapy services. R22's 14 day prospective payment system (PPS) MDS dated [DATE], identified R22 did not walk during the assessment period. The MDS indicated R22 continued to receive both physical and occupational therapies. R22's Falls Care Area Assessment (CAA's) dated 10/5/17, identified R22 had limited mobility, weakness due to recent compression fracture and [MEDICAL CONDITION]. The CAA indicated R22 required extensive assistance of two staff for transfers and most mobility. R22's CAA lacked documentation of R22's ambulation, range of motion (ROM,) physical and occupational therapies and restorative nursing. A Pro Rehab facsimile cover sheet dated 10/25/17, identified R22's physical and occupational therapies had been discontinued secondary to limited progress and participation. A Pro Rehab resident referral interdepartmental communication form dated 10/18/17, revealed PT had placed R22 on an ambulation program directing staff to ambulate R22 twice daily up to 1000 feet with front wheeled walker. The form indicated R22 had difficulty following verbal and tactile cues and directed nursing staff to use assist of one. The form further directed nursing staff that in addition to ambulating twice daily, staff was to ambulate R22 to and from all meals. A Pro Rehab resident referral form dated 10/25/17, revealed R22 was to continue with restorative nursing's stretching and strengthening program of gastroc stretches and hip flexion's as he tolerated. Review of R22's care plan revised 11/3/17, directed facility staff to ambulate twice daily up to 1000 ft with a front wheeled walker and extensive assist of one. R22's care plan indicated R22 had difficulty following verbal and/or tactile cues. Further, R22's care plan directed facility staff to ambulate to and from all meals in addition to twice daily. Review of the Aide Care Plan with a print date of 12/4/17, directed staff to ambulate R22 to meals as tolerated, walk daily with extensive assist of one, and provide active upper and lower extremity range of motion three times a week as tolerated. On 12/7/17, at 7:05 a.m. R22 was lying in bed, eyes closed and covered to mid chest with a blanket. At that time nursing assistant (NA)-C entered R22's room, woke R22, indicated it was time for him to wake up and assisted R22 to wash his face and change his clothing. -At 7:14 a.m. NA-C indicated she did not have the necessary supplies to finish R22's cares and needed to collect supplies. NA-C covered R22 with a blanket and left his room. -At 7:25 a.m. NA-C re-entered R22's room with a package of wipes and an incontinence brief, woke R22 and cued him turn to his right side and hold on to the grab bar on the bed. NA-C removed R22's incontinence brief. R22 was incontinent of bowel, so received peri-rectal hygiene and a clean brief. NA-C assisted R22 to sit on the edge of his bed. NA-C indicated she needed assistance to transfer R22 and used a walkie talkie to call for assistance. NA-C indicated R22 was able to pivot transfer with extensive assistance of two staff. She further indicated there were times when R22 required the use of a mechanical lift to transfer. NA-C stated she felt R22 was unable to ambulate and indicated she had not ambulated him. -At 7:39 a.m. NA-B entered R22's room and along with NA-C, assisted R22 to complete grooming and oral cares. -At 7:42 p.m. NA-B and NA-C assisted R22 to stand. NA-C provided R22 with verbal and tactile cues to move his right foot and indicated R22 had difficulty moving his right foot. At that time R22 indicated he needed to use the bathroom. NA-C and NA-B assisted R22 to sit in his wheelchair, wheeled him to the bathroom door (approximately 5 feet from the bed) and assisted R22 to stand from the wheelchair. NA-C cued R22 to move his left foot and pivot transfer onto the toilet. Both NA-B and NA-C remained with R22 while he voided, NA-B assisted R22 with peri-cares and donning a clean brief. NA-B and NA-C assisted R22 to stand from the toilet. NA-C provided R22 with verbal and tactile cues to move his left foot, both NA-C and NA-B physically assisted R22 to pivot transfer back into his wheelchair. At 8:00 a.m. NA-C wheeled R22 to the dining room, placing him at a table. On 12/7/17, at 8:10 a.m. R22 remained seated in his wheelchair in the dining room, he would briefly lift his head, look around the room then dropped his head to his chest. No staff was observed to interact with R22 or offer R22 food/fluids. A nursing assistant continued to assist the other two residents at R22's table to eat. -At 8:20 a.m. NA-G approached R22, provided him a clothing protector and placed a glass of milk and a glass of orange juice on the table in front of him. R22 picked up the glass of milk and drank 1/4 of the glass. -At 8:25 a.m. a dietary aid (DA)-A served R22 his meal of one over hard egg, two slices of toast, and a piece of coffee cake. The DA-A immediately walked away. R22 ate independently. -At 8:51 a.m. R22 remained seated in his wheelchair in the dining room while he ate his breakfast. He requested a cup of coffee. DA-A served R22 a cup of coffee, which he picked up with his right hand and drank. -At 9:15 a.m. R22 remained seated in his wheelchair in the dining room. NA-D approached R22 and offered an activity. R22 accepted and NA-D wheeled R22 out of the dining room, down the hall and into the activity room. -At 10:06 a.m. R22 remained seated in the wheelchair in the activity room. NA-C approached R22, indicated she was going to bring him to his room, wheeled R22 to his room, and parked his wheelchair facing the television (TV) in his room. -At 10:25 a.m. R22 remained seated in a wheelchair in his room, facing the TV, his eyes were closed, his head dropped to his chest. NA-C and NA-B entered his room and assisted R22 to his bed. No staff were observed to offer or encourage R22 to ambulate to or from the dining room or the activity room. On 12/7/17, at 12:46 p.m. NA-B indicated R22 was totally dependent on facility staff for all ADL's. She indicated she had never walked with R22 to or from the dining room. NA-B indicated she felt R22 would not be able to ambulate. NA-B stated R22's ability to transfer fluctuated over the course of the day and at times R22 required the use of a mechanical lift for transfers. NA-B stated if a resident was on a walking program, the restorative NA's were responsible for assisting residents to walk. She indicated she did not believe residents were receiving any restorative nursing services, included ROM and ambulation. NA-B believed this was due to short staffing. NA-B stated the restorative NA's were routinely pulled to the floor and were unable to complete resident programs. This included programs for R22. NA-B further indicated R22 had significantly declined in ADL performance since his admission. On 12/8/17, at 2:42 p.m. licensed practical nurse (LPN)-B, indicated R22 had declined since admission, including ambulation and transfers. LPN-B stated R22 was supposed to be on a restorative walking program to and from meals and twice daily. LPN-B stated R22 had not been receiving assistance with ambulation since he was placed on the restorative program in 10/17. She indicated there were no staff available to assist R22 or other residents with ambulation or ROM services due to providing other resident cares. LPN-B stated the director of nursing and administrator were aware R22's restorative program had not been implemented. She further indicated she voiced her concerns regarding resident restorative programs and staffing to the director of nursing (DON) and administrator, and had been told they were working on a plan. LPN-B provided a copy of R22's documentation of his ambulation program and indicated she documented a R or Z, which indicated R22 did not receive ambulation services. On 12/8/17, at 10:46 a.m. NA-D indicated R22 was totally dependent on staff for ADL's, including transfers. NA-D stated R22 was supposed to be on a walking program, however due to short staffing R22 had not received assistance with walking. She indicated R22's overall status had declined since his admission, including mobility, incontinence, and cognition. She indicated she had expressed her concerns to the DON about residents not receiving restorative services and had been told they were working on it. Review of R22's treatment administration record (TAR) from 11/17, to 12/17, revealed an order dated 11/6/17, directing facility staff to ambulate R22 to meals three times a day for the ambulation program. The following documentation was provided: -11/17: TAR lacked any documentation R22 had received assistance with his ambulation program. -12/17: TAR revealed from December 1, 2017 to December 8, 2017, the facility nurse had documented R's and Z's. Review of R22's progress notes from 9/28/17, to 12/6/17, revealed the following: -9/28/17 admission note: R22 was admitted to the facility following a fall which resulted in an L1 (lumbar vertebrae) fracture. The note identified R22 was deconditioned and required therapies before returning to his prior living arrangement in a memory care unit. -9/30/17 nursing note (NN): R22 had difficulty sitting upright and would slouch. -10/3/17 NN: R22 had difficulty holding his head up to eat and staff would monitor. -10/5/17 NN: R22 continued to require extensive to total assistance with ADL's. -10/10/17 NN: R22 required the use of a mechanical lift for transfers. -10/13/17 NN: Facility staff attempted to walk with R22 due to restlessness, however he was unable to stand up straight and leaned backwards. -10/15/17 NN: R22 had attempted to stand and walk. -10/17/17 NN: R22 had worked with therapy for approximately 15 minutes. -10/18/17 therapy note: R22 was to ambulate twice daily up to 1,000 feet with front wheeled walker and assist of one. The note indicated R22 had difficulty following verbal/tactile cues. Further, the therapy note also directed facility staff to ambulate R22 to and from all meals with front wheeled walker and assist of one. -10/25/17 NN: R22 attended physical therapy. -10/26/17 therapy note: R22 was to continue with restorative stretching/strengthening program as tolerated. The note indicated R22 needed max verbal cues to begin and continue tasks. R22's nursing progress notes lacked any documentation related his ambulation status including the decline since the 10/18/17 therapy referral to nursing. On 12/8/17, at 10:08 a.m. the nursing supervisor (NS)-A confirmed R22 was on a restorative program which included ambulation. NS-A stated she felt the facility restorative program was not consistently provided to residents which included R22. NS-A stated restorative staff was being pulled to the floor to provide direct care. When that happened, the nursing assistants should complete ROM and assistance with ambulation. NS-A stated she believed R22 could ambulate from his room to the dining room with assistance. A request was made for physical therapy to assess R22's ability to ambulate with staff assistance. On 12/8/17, at 11:00 a.m. director of nursing (DON) indicated she was responsible for the facility restorative nursing program. DON confirmed R22 was on a restorative walking program which directed staff to ambulate with him to and from all meals and twice daily. DON stated she had specifically trained two NA's to ensure restorative programs were provided to residents including R22. She indicated there were times both NA's would be pulled from restorative duties and had to work on the floor due to staffing ill calls. However the DON stated it was not a routine occurrence. She indicated she was unaware R22 had not received assistance with ambulation as directed by PT. She stated she would expect to be notified if resident restorative programs were not offered. DON indicated she ambulated with R22 approximately 30-50 feet on 12/6/17. R22's medical record was reviewed with the DON. No documentation of staff providing ambulation services was found. DON further stated she was unaware of R22's overall decline in mobility. On 12/8/17, at 11:39 a.m. R22 was seated in a wheelchair with a walker in front of him in the therapy department with the physical therapy assistant (PTA)-A and an occupational therapist (OT)-A. R22 had a gait belt on his waist. PTA-A stood on R22's right side and OT-A stood to R22's left side. R22 was provided verbal and tactile cues to push off from the wheelchair armrests and reach for the handles of the walker. R22 stood with extensive physical and verbal assistance. PTA-A provided R22 a tactile cue to move his left foot; R22 then took a couple of steps. R22 leaned to his right side while standing and his left foot dragged on the floor with each step. R22 continued to ambulate with PTA-A and OT-A providing verbal and tactile cues which included, standing straight, looking up and moving his feet. R22 ambulated approximately 20 feet, then he began to lean to his left side. PTA-A and OT-A encouraged R22 to sit down in the wheelchair, R22 shook his head. R22 then took five more steps and was assisted to sit in the wheelchair by PTA-A and OT-A. On 12/8/17, at 11:39 a.m. PTA-A indicated she had previously worked with R22 less than two months ago while he was receiving skilled therapy services. PTA-A stated at that time, R22 was able to ambulate with contact guard assistance of one staff, gait belt and walker approximately 1,000 feet. She indicated R22 was discharged from therapy and had been placed on a walking program. PTA-A stated she felt R22 had declined in his strength, balance, and was no longer able to ambulate 1,000 feet. On 12/08/17, at 4:51 p.m. a telephone call was placed to R22's primary physician who was also the facility's medical director (MD-A). A message was left for a return call. On 12/11/17, at 10:08 a.m. during a telephone interview with MD-A, he indicated he would expect residents restorative programs to be routinely provided to residents, in order to prevent a decline in function. This included R22. MD-A indicated he would expect to be notified of any decline in condition for R22. MD-A further indicated he had been unaware of any changes or decline of condition with R22. A facility policy titled, Restorative Program dated 4/1/08, identified it was the policy of the facility all residents would maintain their highest level of functioning and indicated restorative programs were individualized to meet resident needs. ROM R44's was identified with functional limitations and had not received consistent range of motion services. R44's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], revealed R44 was cognitively intact and required total assistance with all activities of daily living (ADLs). Further, the MDS identified R44 did not walk and had limitations in range of motion to both upper and lower extremities. R44's current care plan revised on 11/10/17, identified R44 had limitation in mobility and ADL performance due to weakness, functional [MEDICAL CONDITION], above the elbow amputation (left arm). The care plan further indicated R44 would receive restorative services for passive range of motion (PROM) to right upper, wrist, elbow, shoulder, and finger flexion/extensions. The care plan also indicated R44 would receive active assisted range of motion (AAROM) to shoulder on right upper extremity and occupational therapy (OT) evaluation for separation fingers on 9/11/17, resting hand splint on right hand to keep fingers 4 and 5 separated. R44's care plan lacked further direction for ROM such as amount, repetitions or frequency. Review of Order Summary Report signed and dated on 11/1/17, by the physician revealed R44 was to receive PROM program one to three times per week with supine bilateral hip extension/flexion, knee flexion /extension, hip abduction/flexion, and ankle in all directions as tolerated. R44's physician orders [REDACTED]. Review of nurses notes from 9/4/17, to 12/5/17, revealed the following: - a therapy note dated 9/15/17, indicated R44 had an OT screen was completed on 9/8/17. The note indicated R44 had been provided a padded resting hand splint with a finger separator. The note further indicated R44 due to R44's fingers had been sticking together, she was to wear the splint at night and periodically through the day as tolerated. - a therapy note dated 9/11/17, indicated an R44 was followed up by OT and had reported she did not like the resting hand splint and was provided with a cone splint with finger separators to be worn at night and periodically throughout the day as tolerated. - a therapy note dated 10/13/17, revealed R44's had been assessed by OT on the following dates, 10/9, 10/10 and 10/12/17. The note revealed that on 10/10/17, R44 demonstrated limited movement of her upper extremity and no active movement of her right hand. The note revealed R44 was to be placed on an upper extremity restorative program for PROM and AAROM as able. The Pro Rehab Nursing Referral for Therapy Screen dated 9/6/17, indicated OT recommended R44 wear a resting hand splint with finger separators at night and periodically through out the day. An OT note indicated R44 was screened on 10/9/17, in bed, demonstrated ability to perform minor movements in direction of shoulder internal rotation with right upper extremity, trace wrist flexion and no active movement of right hand. On 10/10/17, was placed on a restorative program. The Resident Referral Interdepartmental Communication form dated 10/10/17, indicated R44 was to be placed on a daily restorative program for right upper extremity ROM as ordered: PROM to right upper extremity, finger flexion/extensions as able, wrist flexion/extension, ulnar/radial deviation, elbow flexion/extension, shoulder flexion/extension and horizontal abduction/adduction. Right upper extremity for AAROM: shoulder internal/external rotation. During observation on 12/5/17, at 7:32 p.m. R44's right hand was closed and she was not wearing a splint to her right hand. R44 indicated at this time that therapy was not working with her and she did not have a splint for her right hand. R44 indicated she has asked staff about therapy, but has gotten no answers. R44 indicated she had talked to the DON a while ago about therapy and she said she would talk to them and report back to her. During observations on 12/7/17, at 7:08 a.m. R44 was lying on her left side sleeping in bed. Her right hand was resting on her stomach. R44 had no splint device on her right hand while sleeping and her left arm was amputated above the elbow. At 7:42 a.m. R44 continued in the same position and had her call light on. At 7:46 a.m. LPN-A answered the call light and R44 stated she wanted to get up. LPN-A told her it would be a minute and shut her call light off. At 8:15 a.m. R44 remained unchanged when NA-B entered her room. R44 told her she wanted to get up and has been waiting since 7:00 a.m. NA-A left the room, telling R44 she would be back. At 8:18 a.m. NA-B and NA-C entered room to assist R44 with cares and getting up for the day. At 8:42 a.m. NA-C wheeled R44 out of her room to the dining room for breakfast. R44 had no splint device to her right hand. At 9:13 a.m. R44 was returned to her room and settled in front of the TV. No splint was applied. During observations on 12/8/17, at 8:56 a.m. R44 was seated in her wheelchair in her room and had no splint device to her right hand. The splint was not visible in her room. At 11:16 a.m resident lying in her bed on her left side with no splint device to her right hand. At 12:43 p.m. OT-A entered R44's room and looked at R44's right hand while she was laying in bed on her left side. The OT-A assessed R44's right hand and determined there was no decline. R44's splint was sitting on her bedside table across the room. At 12:45 p.m. R44 indicated to the OT that staff do not put her splint on at night so she has not been wearing it. The OT-A stated R44 had the splint in place for about a month and a half. The OT-A further stated restorative services only got done when staff have time. On 12/8/17, at 8:56 a.m. R44 indicated staff did not provide therapy services. She further stated she has not been using a splint device for her right hand. R44 indicated the only therapy services she got was what she was able to provide herself. R44 indicated staff didn't do nothing with her legs. R44 stated staff did therapy a few times then they quit. R44 stated she did not know why they quit providing therapy services. R44's Medication Administration Record [REDACTED]. Review of the MAR from October to December 2017 identified the following information: 10/17 - no documentation that R44 had received restorative nursing services; 11/17 - R44 received services one day for the month; 12/17 - R44 received no services to date (12/8/17). On 12/8/17, at 10:31 a.m. NA-B confirmed R44 was totally dependent on staff for all ADL's and had little movement with her right arm. NA-B indicated R44 had a brace for her right hand but was not sure if she was suppose to wear it at night or during the day. I don't know. NA-B indicated she did not put the splint on R44's right hand. NA-B was not sure if R44 received therapy or restorative nursing and stated she did not provide those services. NA-B indicated the nursing staff did not have time to do restorative nursing. NA-B further said the facility did not have a restorative aid during the day. NA-B stated it had been a month or so since they had a restorative aid working with residents. NA-B also stated R44 did not refuse her cares when offered. On 12/8/17 at 10:49 a.m. RN-A confirmed R44 was totally dependent on staff for all ADL's and had a contracture to her right hand. RN-A indicated R44 was pretty pleasant and never refused cares. RN-A indicated R44 had no movement in her right arm and was not sure if she had a splint device. RN-A confirmed she did not see anything written on R44's Medication Administration Record [REDACTED]. RN-A indicated she thought staff was suppose to provide ROM to R44 during cares and nurses were suppose to document ROM in the MAR. RN-A verified R44's MAR's for 11/17, and 12/17. were incomplete and had not been signed off that restorative nursing had been completed for R44. RN-A indicated she could not confirm if R44 received restorative nursing during this time. RN-A believed restorative nursing was getting done, but indicated it was not perfect and staff was not consistently providing it. On 12/8/17, at 12:33 p.m. the OT-A R44 was not a candidate for therapy and would function better on the restorative program. The OT-A indicated R44 was to receive PROM to her fingers, wrists, elbows, and shoulder. The OT-A confirmed R44 currently had a contracture in her right hand and was given a resting hand splint to be worn at night and during the day. OT-A indicated R44 had a different splint and did not like it, so she was given a cone splint with finger separators. OT-A indicated the staff should be aware of R44's splint and the wearing schedule, because they were updated on her splint. OT-A indicated she did not know if staff were doing restorative nursing with R44. OT-A indicated she has been working with the DON to have two NA's learn how to do it. On 12/8/17, at 12:52 p.m. NA-D indicated a few staff members have been trained on restorative nursing and the rest have not. NA-D indicated restorative nursing was not getting done on a daily basis due to not having enough staff on the floor. The restorative aids were pulled to work the floor. NA-D indicated R44 had not been receiving her restorative nursing and has not been getting the splint to her right hand. Staff was not providing the restorative nursing services. On 12/8/17, at 1:00 p.m. the DON indicated R44 had a therapy screen done and was given a brace for her right hand. The DON indicated the nurse was to do ROM before the brace was placed and after the take the brace was removed. DON indicated the nurses were responsible to make sure R44 was wearing her brace. DON indicated she did not know if restorative nursing was getting done, but assumed her staff was doing it. The DON indicated her expectations of staff were to make sure they were doing active and passive ROM and to have R44 wear her splint to her right hand. The DON indicated each staff member had a pocket care guide they were to carry in their pocket and she would expect staff follow the care plan as written. On 12/8/17, at 5:35 p.m. NA-F confirmed she did not provide any restorative nursing programs on the evening shift and only walked a few residents. NA-F indicated she was told what she was suppose to do for restorative but not really trained on the program. NA-F indicated she has been pulled to work the floor, which happens quite a bit due to the facility being short staff. NA-F confirmed R44 was not receiving restorative nursing on a regular basis and was not receiving the splint device to her right hand at night. NA-F also indicated if staff call in she was pulled to the floor to work and did not get a chance to work with restorative nursing programs. R37's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], revealed R37 was moderately cognitively impaired and was independent with all ADL's. Further, the MDS identified R37 had no limitations in ROM to both upper and lower extremities. The MDS indicated R37 was steady at all times with moving from a seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet, and surface to surface transfers (transfer between bed and chair or wheelchair). R37's current care plan revised on 11/2/17, identified R37 was at risk for a decrease in ROM. The care plan identified R37 would maintain current level of ADL and ROM function and would receive restorative nursing three to five times per week for active range of motion (AROM) with rowing machine, weights, fit and fabulous AROM program, and NuStep bike under the direct supervision of nursing staff member. R37's Aid Care Plan Group A undated, indicated R37 was to receive AROM and strength training three to five times per week on the NuStep, arm bike as tolerated (max 15 minutes). The care plan lacked any further information on R37's exercise program. Review of nurses notes from 8/3/17 to 12/8/17, revealed a noted from physical therapy (PT) dated 10/24/17, identified a screen revealed R37 not appropriate for a skilled service at this time and therapy set up a restorative strengthening program. R37 would have use of upper body extremity and NuStep with direct supervision of nursing staff at all times when in therapy department. Another nursing noted dated 11/2/17, indicated R37 would be on a ROM and strengthening program, maintain current ADL score and ROM, start program, may use NuStep, rowing machine, and weights under direct supervision of nursing staff member, three to five times a week. Encourage to participate in daily AROM fit and fabulous program. The Pro Rehab Nursing Referral for Therapy Screen dated 10/19/17, indicated referred to PT for gait disturbance upon standing due to low back pain. PT recommended restorative strengthening program with use of upper body extremities and NuStep in therapy department. R37 must have direct supervision of nursing staff when in the therapy department doing restorative program. On 12/7/17, at 7:26 a.m. R37 was seated in a recliner in the activity room across from the nursing station watching TV with his walker at his side. At 7:31 a.m. R37 got up from the recliner independently, and walked independently down to the dining room. At 8:13 a.m. following breakfast, R37 got up from dining room table independently, and walked independently back to the activity room. At 8:23 a.m. R37 walked down the hallway to his room. At 10:23 a.m. R37 walked to the other end of the facility with walker to visit another resident. At 10:50 a.m R37 was sitting on the edge of his of bed with walker at his side. At 10:54 a.m. R37 walked independently to the therapy room. R37 asked therapy staff about exercising. Therapy staff explained to R37 that a restorative aid has to be with him to exercise. R37 was unable to exercise. At 10:57 a.m R37 visited with administrator about his exercise program and wanting to use the exercise equipment. R37 told the administrator that therapy would not let him use the equipment without restorative nursing staff. R37 indicated to the administrator he needed restorative services for mental health and the administrator explained that he needed staff with him for safety. At 10:59 a.m R37 walked independently with the administrator to the DON office to talk to the DON about his restorative program. At 11:00 a.m. the administrator told R37 he would see if the machines were being used and if not he would get an NA to stand by and watch him. R37 stated watch me so I don't have a [MEDICAL CONDITION] in a very frustrated tone of voice. R37 indicated he wanted to exercise to keep his back muscles strong. At 11:07 a.m. the DON came back to her office. R37 told the DON he went down to therapy and he could not exercise. The DON told R37 he had therapy in the afternoons. R37 continued to be very frustrated about his restorative exercise program. At 2:30 p.m. R37 walked to the therapy room without his walker, sat down in a chair next to the NuStep machine with no staff present. Therapy staff was in the office charting. R37 continued to wait while he sat in the chair staring at the floor. At 2:40 p.m. R37 continued to be seated on a chair in the therapy room next to the NuStep machine, when nursing supervisor (NS)-A approached R37 with staff members home health aid (HHA)-A and HHA-B, both wearing their winter coats. R37 transferred independently to the NuStep machine after direction from NS-A. NS-A then left the room. HHA-A and HHA-B indicated they did not know how the NuStep equipment worked. R37 remained on the seat of the NuStep waiting. PTA-A came out of the office and began to show HHA-A and HHA-B how to place R37's feet on the peddles and how to adjust the machine for his size frame. At 2:45 p.m. HHA-A indicated that she had already clocked out for the day and was going to go home. HHA-A indicated she came back to help R37 with the NuStep because R37 wanted to exercise. She works over in assisted living and was not sure who was working the restorative nursing program today. HHA-B indicated she was

Based on observation, interview and document review, the facility failed to provide ambulation services to prevent loss of function for 1 of 4 residents (R38) who required assistance with ambulation. R38 was not provided assistance with ambulation and was not re-assessed upon a decline in ambulation. R38's decline in the ability to ambulate resulted in actual harm. Findings include: R38's significant change Minimum Data Set (MDS) 9/26/16, identified R38 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R38 was independent in bed mobility, transfers and used a wheelchair independently for locomotion. Further, the MDS identified activity did not occur for turning around and facing opposite direction while walking and R38 did not walk. R38's ADL Care Area Assessment (CAA) dated 9/26/16, indicated R38 had improved ADL performance and would be addressed on care plan. The CAA did not address R38's ambulation. R38's admission MDS dated [DATE], identified R38 was not steady, only able to stabilize with human assistance for walking and turning around and facing opposite direction while walking. The identified R38 had ambulated with limited assistance from staff. R38's ADL CAA dated 5/24/16, identified R38 required assistance from staff to safely ambulate and transfer. The CAA revealed R38 was receiving therapies and her goal was to return to independence in hopes of returning home. R38's Behavioral CAA dated 5/24/16, identified R38's goal was to cooperative with therapies in order to return home. On 10/18/16, at 1:36 p.m. R38 was observed in the facility hallway, seated in a wheelchair, propelling herself to the activity room with both feet. R38 propelled herself up to a squared table, opened the daily newspaper and began to read the paper. On 10/20/16, at 1:38 p.m. R38 indicated she had wheeled herself into the bathroom and slid herself to the toilet seat to use the toilet. She stated she was able to complete most cares for herself and liked to be as independent as possible. R38 proceeded to propel herself out of her room, utilizing both feet to the activity room to attend an activity. At 3:08 p.m. R38 was seated in her wheelchair in the activity room actively participating in Bingo. R38 was not observed to ambulate at any time during observations. On 10/20/16, at 1:57 p.m. nursing assistant (NA)-F stated R38 used a wheelchair for mobility and was able to propel herself to and from destinations. NA-F stated R38 was independent with all of her personal cares and liked to maintain her independence. NA-F stated she did not think R38 was able to walk and had never assisted R38 to ambulate. NA-F stated the nursing assistants were responsible to ambulate residents who were on an ambulation program and stated she did not think R38 was on an ambulation program in the facility. On 10/20/16, at 2:30 p.m. NA-B stated she had not assisted R38 with ambulation at any time in the past. NA-B stated the NA on the individual units were responsible for residents walking programs, after the program had been determined by occupational (OT) and physical therapies (PT). NA-B stated R38 had received both PT and OT upon admission for a few months and indicated she was unsure if R38 had been placed on the ambulation program. NA-B stated she felt R38 was unable to fully stand nor could R38 ambulate. NA-B stated the NA on the unit often times could not assist residents with their ambulation programs due to not enough NAs on the floor. On 10/20/16, at 3:18 p.m. licensed practical nurse (LPN)-B stated the NAs on the units were responsible to ambulate with residents who had ambulation programs in the facility. LPN-B stated she was unsure if R38 was on an ambulation program at present and after review of R38's clinical record, confirmed R38 had a referral from PT and OT dated 7/8/16, which directed R38 was to be assisted with ambulation twice daily with a walker and one-person assistance up to 40 feet. LPN-B stated she did not think R38 had been assisted to ambulate since therapy ended. On 10/21/16, at 10:35 a.m. registered nurse (RN)-A stated she was unaware if R38 was on an ambulation program and indicated she had not seen R38 ambulate with staff in the past. On 10/21/16, at 11:20 a.m. physical therapy assistant (PTA) stated R38 had received both physical and occupational therapy upon admission to the facility in May of 2016. PTA stated R38 was discontinued from both therapies in July 2016, with a referral to nursing for R38 to be placed on an ambulation program with nursing staff. PTA stated R38 was able to ambulate with one assist and a front wheeled walker up to 40 feet consistently, when PT and OT were stopped. PTA stated she had serious concerns with residents' ambulation and maintenance programs being completed consistently. PTA stated felt there was not enough nursing staff in the facility to complete ambulation and maintenance programs on a routine basis. On 10/21/16, at 11:30 a.m. R38 stated she was no longer able to walk and used a wheelchair to move about the facility. R38 stated she had been walking when she was admitted to the facility and had worked with therapy for her walking. R38 stated nursing staff had not assisted with her ambulation since therapy had stopped several months ago. R38 stated she had bad knees which affected her ability to walk, but felt if she had some treatments she would be able to walk again with help. On 10/21/16, at 11:36 a.m. PTA entered R38's room, and looked in her closet and various locations in her room for her walker. PTA stated R38 no longer had a walker in her room and stated she would expect R38 to have a walker available so nursing staff could assist her to walk. PTA left R38's room briefly, returned with a front wheeled walker and placed the walker in front of R38. PTA applied a transfer belt around R38's torso and cued R38 to stand from her wheelchair up to the walker while PTA pulled upwards on the gait belt. R38 was only able to lift her buttocks from the wheelchair seat approximately 7 inches. R38's knees remained bent at approximately an 80 degree angle, was unable to stand fully erect or straighten her knees. PTA attempted to stand R38 twice more and R38 continued to not able to stand erect or straighten her knees. R38 stated she could not stand up all of the way and had not stood up for a long time. R38 stated she could not remember the last time she had used a walker. PTA asked R38 when the last time she had walked and R38 responded, with you. PTA confirmed the last time she had worked with R38 was in July, 2016. PTA confirmed R38 had lost the ability to fully stand and to ambulate. On 10/21/16, at 11:44 a.m. during a follow up interview, PTA stated when R38 was discharged from therapy, R38 had been ambulating about 40-60 feet daily with minimal assist of one and a front wheeled walker. PTA stated R38 was referred to an ambulation maintenance program and she would have expected R38 to receive assistance with walking with nursing staff twice daily. PTA stated she felt the facility had a huge problem with the facility's ambulation/maintenance program due to staffing concerns and stated she felt there were not enough NAs to complete resident ambulation/maintenance programs. Review of R38's hospital discharge summary dated 5/17/16, identified R38 had been treated for [REDACTED]. The summary revealed R38 was having difficulty standing and walking. The summary further revealed R38 was sent to the facility for acute rehab due to lower extremity weakness. Review of R38's physician progress notes [REDACTED]. The note also revealed R38 had plateau in therapy, however, was ambulating using a walker. The note further revealed R38's daughter had concerns that R38 had exhibited regression after therapy was ended. Review of R38's physician progress notes [REDACTED]. The note revealed R38 used a wheelchair for long distances, had received PT and OT during the spring and summer, and at that time due to increased care needs R38 was determined to be a long term patient. R38's current care plan updated 6/10/16, indicated she was fully ambulatory with a walker and contact guard assistance. R38's care plan also indicated R38 was receiving therapy and assist to transfer with one and gait belt, and R38 wheeled self independently in wheelchair. R38's care plan did not identify any updates past 6/10/16. Review of the Aide Care Plan Group C form, dated 10/17/16, listed various interventions which included R38 was assist of one for transfers, toileting and ADL's, and listed R38 received therapy for walking. The form did not list any other interventions for R38's ambulation. Review of a facility form titled, Resident Referral Interdepartmental Communication dated 7/8/16, revealed therapy had referred R38 to nursing for a ambulation program to include ambulation twice daily with front walker and one assistance up to 40 feet. The form also identified R38 has complained of left knee pain and if nursing had any questions to call. Review of R38's medical record revealed the record lacked further documentation of R38's ambulation status or progress and lacked documentation of facility forms maintenance ADL worksheets. Nursing progress notes were reviewed from 5/17/16, to 10/18/16, revealed the following: On 5/17/16, R38 was full weight bearing and required one assistance with ADL's. On 6/10/16, the note indicated R38 was working with therapy. On 6/11/16, R38 questioned nursing staff on when she would be able to return home. On 8/4/16, R38 required one assist with ADL's. R38's nursing progress notes lacked any documentation of R38's ambulation and decline in R38's ambulation status. On 10/21/16, at 1:37 p.m. the assistant director of nursing (ADON) confirmed R38's ambulation/maintenance program had never been implemented in July. ADON stated the nurse managers were responsible to ensure therapy referrals for ambulation/maintenance programs were started once a resident was referred. ADON stated the nurse manager was responsible to initiate a facility form titled, Maintenance Activity of Daily Living (ADL) worksheet which would direct the NA on what type of assistance with ADL the individual resident needed and the frequency of the maintenance program. ADON confirmed R38's referral for ambulation maintenance program directed staff to ambulate with R38 with a front wheeled walker up to 40 feet twice daily. ADON stated she would expect R38's ambulation program to be implemented to maintain and prevent further decline her ambulation. ADON stated she felt the facility's ambulation/maintenance program was not getting done due to staffing concerns and stated she felt the NA did not have the time to complete all residents programs, including R38. On 10/24/16, at 9:27 a.m. nurse manager (NM)-A stated she had understood the nursing assistants had been assisting R38 with ambulation. NM-A stated she was not aware R38 could not longer ambulate. NM-A stated she was not sure why R38's ambulation/maintenance program had not been started. On 10/24/16, at 9:58 a.m. R38's Advanced Practice Registered Nurse/Certified Nurse Practitioner (NP)-A stated R38 had recently established care with her in early October. NP-A stated she would expect the facility staff to follow through with therapy referrals for ambulation/maintenance programs and she would have expected R38 to be assisted with ambulation per the therapy referral. NP-A stated R38's previous primary physician had last seen R38 in August and may have more to comment on R38's loss of ambulation. A message was left for R38's previous primary physician, but the physician did not call back during survey. A facility policy titled, Restorative Program, dated 4/1/08 identified residents would be assessed on admission for a restorative program such as ambulation. If a ambulation program was an identified need, a plan would be individualized to meet resident needs and goals. The policy further identified residents would be supported and their highest level of functioning maintained.

Based on observation, interview and document review the facility failed to provide range of motion (ROM) services and hand splints to prevent further decline in ROM for upper extremities for 1 of 4 residents (R66) reviewed for ROM. This deficient practice resulted in actual harm for R66. Findings include: R66's quarterly Minimum Data Set ((MDS) dated [DATE], identified R66 had [DIAGNOSES REDACTED]. The MDS identified R66 had severe cognitive impairment, and was totally dependent on staff for assistance with all activities of daily living (ADLs). R66's MDS identified R66 had functional limitations in range of motion on both sides, upper and lower extremities, and did not receive therapy services or restorative nursing services. R66's annual MDS dated [DATE], identified R66 had severe cognitive impairment, and was totally dependent on staff for assistance with all ADLs. The MDS identified R66 had functional limitations on both sides, upper and lower extremities, and did not receive therapy services or restorative nursing services. R66's Care Area Assessment (CAA) dated 1/11/16, identified R66 was dependent on staff for all ADLs related to [MEDICAL CONDITION] over the last year, and had difficulty with mobility, communication and cognition. R66's care plan dated 2/18/16, identified R66 was aphasic (non verbal) due to [MEDICAL CONDITION], and was unable to make her needs known. R66's care plan also identified R66 was to wear hand splints for 2 hours on and 2 hours off during the day, and was to wear the splints all night. R66's care plan failed to identify R66 had contractures, and did not identify a ROM or a restorative nursing program for R66 to prevent further decline. Review of the Aide Care Plan, Group B dated 10/17/16, identified R66 required total assistance with cares and was to wear hand splints on and off every 2 hours during the day and leave them on all night. The Aide Care Plan did not identify R66 had contractures or that she required a ROM or restorative nursing program to prevent further decline. R66's Admission Assessment form dated 12/31/15, indicated R66 was non verbal, was non-weight bearing, transferred with a mechanical lift, and had elbow contractures. R66's Admission Assessment form indicated R66's hand grasps had not been assessed. Review of R66's Resident Referral Interdepartmental Communication form dated 1/12/16, identified directions for nursing to complete R66's passive range of motion (PROM) to both upper extremities, active range of motion (AROM) to left hand, and included instruction to have R66 open and close fingers and to have R66 squeeze staff's hand with her left hand daily to maintain strength. Review of a second Resident Referral from therapy dated 2/18/16, identified R66's hand splint wearing schedule as for R66 to wear splints 2 hours on, 2 hours off throughout the day and on at night. R66's progress notes reviewed from 1/3/16 to 10/17/16 identified: -1/3/16, R66 reached over and grabbed the TV remote with her left hand and could hold her TV remote in her left hand. -1/21/16, R66 was changing TV channels with remote. R66's progress notes lacked further documentation regarding communication skills or techniques and lacked any documentation of upper extremity motion, exercises, or decline in function. Review of R66's physician progress notes [REDACTED]. -2/9/16, identified R66 suffered a [MEDICAL CONDITION] in 12/14, had been in a former long term care facility, but family had requested a transfer closer to their home. R66's could not communicate verbally. Nursing had reported R66 did not communicate verbally but was able to push her call light button and could change the channel on her TV with her TV remote. -3/17/16, identified R66 still had some movement which involved the left upper extremity, and the physician would make sure therapy had a maintenance regimen from a contracture and general limb standpoint for R66. -10/6/16, identified R66 could squeeze his fingers with left hand. On 10/19/16, observations from 7:00 a.m. to 9:47 a.m. were conducted: -At 7:00 a.m., R66 was observed lying on her back in bed, with her eyes closed. Both R66's arms were bent at the elbow, her right hand was in a fist position on her chest, and her left hand was in a C shaped position with fingers bent and hand slightly tilted away from her body. Splint devices were not observed on either of R66's hands, and the splint devices were not observed in her room. -7:49 a.m. licensed practical nurse (LPN)-A entered R66's room to provide her trachea (artificial opening at windpipe) site care. She confirmed R66 was not wearing hand splints and stated R66 had not been wearing them in the recent past because she thought the splints were uncomfortable for R66. LPN-A exited R66's room and did not apply R66's hand splints. -8:03 a.m. the nurse consultant walked in R66's room and immediately walked down to the nurses station. R66 remained on her back in bed, with her hands and arms in the same positron, no splints observed. -8:20 a.m. R66 remained lying in bed in the same position with R66's arms bent at her elbows and her hands rested on her chest in the same position. No hand splints were observed on R66's hands and splints were not observed in R66's room. -9:47 a.m. R66 remained in the same position in bed, no hand splints were observed on R66 or present in R66's room. On 10/19/16, at 10:03 a.m. LPN-A confirmed R66 had not worn hand splints and stated R66 did not wear the splints at all. She stated she was not aware when R66 last had worn the splints and indicated she thought it had been in the distant past. LPN-A left room and did not apply hand splints to R66. On 10/19/16, at 10:33 am nursing assistant (NA)-E confirmed R66 did not routinely wear hand splints, and stated she could not remember the last time R66 had worn her splints. NA-E provided a copy of the a NA care sheet and confirmed the care sheet directed for R66 to wear hand splints. She stated she had not been aware R66 was to wear hand splints. NA-A and LPN-A exited R66's room and did not apply her hand splints. On 10/19/16, at 10:40 a.m. NA-D stated she was not aware of how R66's care plan directed her to care for R66. She stated she was not aware if R66 had hand splints or if R66 was supposed to wear them. On 10/19/16, at 12:10 p.m. R66 was seated in her recliner in her room with both hands resting on her chest, right hand in fist, left hand curled in a C shape. R66 did not have hand splints on either hand. On 10/20/16, at 9:30 a.m., during follow up interview, NA-B stated R66 presently did not receive range of motion services or presently was not receiving a restorative nursing program. On 10/20/2016, at 9:36 a.m., during follow up interview, NA-D stated R66 did not routinely use her hands and was not aware if R66's hand stiffness had gotten worse. She stated she was not aware if R66 was on a restorative program or received range of motion services. NA-D reviewed the therapy referral in the nursing assistant reference book at the nursing station and stated she felt R66's therapy screening was not current, and R66 did not need range of motion services and did not need to wear splints since the screen was old (February 2016) She stated she was sure R66 got enough range of motion when they dressed her. On 10/20/16, at 9:45 a.m. assistant director of nursing stated she was not aware if R66's splints had been discontinued in the past and indicated she questioned if the splints bothered R66 and indicated she felt R66 was not anymore contracted than when she was admitted . On 10/20/16, at 10:03 a.m. occupational therapist (OT)-A stated R66 had worn hand splints at the time of admission, and indicated she was not aware if R66 had contractures on admission. She confirmed R66's therapy screens on 1/12/16 and 2/18/16, and indicated the therapy screen on 2/18/16, was completed after the facility changed the style of splint for R66 per family request. She stated a comprehensive assessment of R66's contractures had not been completed because the facility did not have a physician order [REDACTED]. OT-A stated the facility NAs were responsible for providing ROM services, restorative program and applying R66's splints and indicated the facility had a book of recommendations for residents' programs at the nurses desk. She confirmed R66 was unable to move both hands or her fingers independently. She stated she felt R66's left fingers were tighter, and flexion and extension was slightly limited, and stated she felt R66's limitations were within normal limits. She stated she felt R66's hands weren't contracted but had high tone. She confirmed the ROM and the splints were recommended treatments for R66's high tone. She stated she would expect R66 to wear the splints all night and alternating on and off every 2 hours throughout the day since 12/31/15, and should have received ROM services since 1/12/16. At approximately 10:10 a.m., NA-B entered R66's room and OT-A asked her to locate R66's hand splints. NA-B looked in R66's bedroom in various locations and found them on R66's wheelchair underneath blankets and equipment. OT-A stated R66 should have been wearing her hand splints according to the schedule to prevent further functional decline. NA-B stated R66 had not worn the hand splints in awhile, and stated she was not sure why R66 had not been wearing them. On 10/20/16, at 10:35 a.m. LPN-A stated she felt R66's care plan did not include a restorative program or ROM that she knew of. She confirmed R66's care plan and stated that ROM services were not on R66's care plan. She stated R66 had never used hand splints, and she felt R66's ROM, Was about the same. On 10/20/16, at 10:37 a.m. certified occupational therapy assistant (COTA) stated their usual process for implementing a ROM program for residents was to complete a therapy screen and give a copy of the recommended ROM program to the clinical manager (CM.) She stated once the CM received the plan she was expected to implement the program with NAs and set up the Maintenance ADL Worksheet, in the NA Book for documenting ROM provided. She confirmed there was no documentation that ROM services were provided for R66 in her medical record or in the NA Book. She confirmed R66 should have received ROM services since 1/12/16, and stated she could not explain why she never received ROM services. On 10/20/16, at 10:40 a.m. NA-B stated she felt R66's stiffness had gotten worse and her arms were more stiff now. She stated she noticed R66 was more stiff when they dressed her, and stated they really had to manipulate her arms when they put her shirts on. On 10/20/16, at 11:45 a.m. OT evaluated R66's elbow ROM while R66 was awake in her bed. OT physically picked up R66's right arm and after she manipulated both arms, she confirmed R66's right elbow lacked 25% extension. She confirmed R66 was a little tight with initial right side movements, and confirmed R66 grimaced in pain with movement. She confirmed R66 also had pain and grimaced with movement of her left arm, and R66's left elbow lacked about 10% for extension. On 10/20/2016 at 12:00 p.m. NA-D stated sometimes R66 was a little more stiff in her upper extremities, and staff had to manipulate her arms more depending on the shirt they were putting on her. On 10/21/16, at 10:14 a.m. NA-A stated R66 was totally dependent on staff for all of her cares. She stated she was unsure if R66 was on a ROM program , but stated she felt R66 should be. She stated she knew R66's right arm was more stiff than her left arm. She stated R66 just started wearing hand splints to both hands today and stated she had never seen R66 wear see hand splints until today. On 10/21/16, at 2:16 p.m. R66 was observed on her back in bed with both arms resting on chest, right hand in a fist, left hand in a C shape. No splints were observed on either of R66's hands. A 8.5 X 11 white piece of paper with both typed instructions and hand-written notes, dated 8/3/16, was observed posted on R66's bedroom wall across from her recliner and identified R66's TV show preferences. On 10/21/16, at 2:55 p.m. speech language pathologist (SLP) stated she had been working with R66 on communication techniques and assessed her ability to use her hands and elbows in the past. SLP repeated her functional assessment of R66. R66 was reclined in bed and SLP held Yes and No flash cards above R66's chest. SLP instructed R66 to point at the card that answered her questions. R66 unable to point or motion hand toward cards. SLP instructed R66 to use her eyes to look at either card to answer her questions. R66 was unable to participate in the assessment at all. R66 began crying and SLP ended assessment. SLP confirmed R66 had 0% success today, where R66 responded correctly to 60% of her questions during a past assessment. On 10/24/16, at 9:50 a.m. NA-B stated at present, she was not aware if R66 could use her call light , and stated she did not know if R66 could hold a TV remote or use it. On 10/24/16, at 10:14 a.m. NA-D stated R66 might be able to use her call light or TV remote if you put them in her hand, but wasn't sure. On 10/24/16, at 10:38 a.m. registered nurse (RN-A) stated R66 had severe cognitive impairment and was totally dependent on staff for all cares. She stated she was unaware if R66 was on a ROM program, wore her arm splints before today, or had declined in ROM to her upper extremities. She stated R66 should have received ROM and wore her arm splints according to the therapy recommendations and confirmed ROM was not on R66's care plan. On 10/24/16, at 10:53 a.m. clinical manager (CM)-A stated R66 had severe cognitive impairment, and was dependent on staff for cares. She indicated she thought R66 had contractures on admission, but stated she did not remember where the contractures were, or which side of R66's body was affected. CM-A stated she remembered talking to the physician in the distant past about R66's contractures after admission and stated she told him she saw R66 use her TV remote in her room. CM-A stated R66 was supposed to get ROM since 1/12/16, and was to wear hand splints on and off during the day, and keep on all night. She stated she expected R66 to wear her hand splints according to the schedule and receive ROM services from the NA's. She confirmed there was no documentation in R66's medical record or in the NA book that R66 had ever received ROM services since admission. She confirmed ROM services were not on R66's care plan. On 10/24/16, at 12:00 p.m. COTA evaluated R66 while she was awake and sat in her recliner. COTA picked up R66's right arm by her elbow and put her call light in between R66's finger and adjusted her fingers to hold call light. R66's fingers were very weak and her fingers and hand didn't move and the call light fell on her lap. COTA picked up R66's left arm by the elbow, placed her call light between R66's fingers. R66's left hand and fingers did not move. R66 hand and fingers were very weak and call light just sat loose in her hand and R66 could not grasp or activate her call light. COTA also evaluated R66 for holding her TV remote. COTA attempted to place R66's TV remote in R66's right hand while she supported R66's arm by her elbow. R66 was unable to hold the TV remote at all with her right hand or fingers. COTA lifted R66's left arm up by the elbow and put the remote between R66's left fingers. The TV remote slipped in R66's hand and pointed up to the ceiling. R66 was unable to hold the remote towards her TV or activate the remote with her left hand and fingers. She stated she was sure R66 declined in her upper extreme ROM. On 10/24/16, at 12:27 p.m. Activities Director (AD) confirmed activity staff had posted a paper in R66's room at the time of admission, which listed TV shows R66 like to watch. AD indicated at the time the sign was originally posted, R66 could hold and use the remote, and liked to channel surf on the TV and would stop on the shows she liked to watch. On 10/24/16, at 1:45 p.m. nurse practitioner (NP) stated she felt if R66 was unable to use her remote or call light now, and could on admission, it was evidence of a functional decline. She stated the failure to provide ROM services was not a new concern for her and stated she had brought her concerns to administration in the past, but continued to be a long standing problem in the facility. On 10/25/16, at 5:05 p.m. family member (FM)-A stated when R66 first got to the facility she could use her TV remote, change the channels, use her call light, and write her name and the word Mom. She stated when R66 was first admitted to the facility R66 could also pull her covers up, put her arms in the arm holes of her night gown. FM-A stated R66 could no longer do any of those things and indicated she felt R66 was sad and frequently cried. She stated R66's right side was most affected by her [MEDICAL CONDITION]. She stated she had visited R66 over the previous weekend and noticed staff were now putting the hand splints on both hands. and stated she felt the facility should of been using the hand splints for R66 the whole time. FM-A stated she had never seen staff do any exercises with R66 for her hands and arms, and stated she didn't know if they ever had. She stated R66 received ROM all the time before admission to this facility. She stated she had asked facility staff why R66 did not get ROM exercises and stated she had been told by staff they felt her brain was not working enough for them to do that. Review of facility policy, Restorative Program, dated 4/1/08 identified residents would be assessed on admission for a restorative program such as ROM. If a ROM program was an identified need, a plan would be individualized to meet resident needs and goals. The policy further identified residents would be supported and their highest level of functioning maintained.

Based on observation, interview and document review, the facility failed to comprehensively assess a resident's falls to determine whether new interventions should have been implemented to decrease the risk of further falls for 1 of 3 residents (R78) reviewed for accident hazards. This deficient practice resulted in harm for R78 who sustained a hip fracture with a fall. Findings include: R78's quarterly Minimum Data Set ((MDS) dated [DATE], identified R78 had [DIAGNOSES REDACTED]. The MDS identified R78 had moderate cognitive impairment, required limited assist to transfer, walking, toilet use and was occasionally incontinent of urine, continent of bowel and was not on a toileting plan. R78's quarterly MDS dated [DATE], identified R78 had intact cognition, required limited assistance to transfer, walk, toilet and for personal hygiene, was occasionally incontinent of urine, continent of bowel and was not on a toileting plan. R78's significant change MDS dated [DATE], identified R78 had moderate cognitive impairment, was totally dependent upon staff for transfers, dressing and toileting, was occasionally incontinent of urine, continent of bowel and was not on a toileting plan. R78's Care Area Assessment (CAA) dated 10/3/16, identified R78 had confusion, disorientation, forgetfulness and needed reassurance, reminders to help make sense of things. The CAA identified R78 had experienced a decline in condition related to fall with fracture and surgical intervention and incontinence. R78 was receiving therapy services with goal established for toileting transfers. R78 had been impulsive leading to poor safety awareness and had a history of [REDACTED]. R78's care plan revised 9/28/16, indicated R78 had a self care deficit related to cognitive loss, unsteady gait and transfers, was at risk for falls related to history of falls, unsteady gait, incontinence and poor judgment related to dementia. The care plan indicated R78 used a urinal at night per his request, App (concave) mattress related to decreased mobility, transfer with hoyer (full body lift) and two staff, floor mats beside bed, rearrange room to allow extra room for mobility. The facility form titled Aide Care Plan Group B, dated 10/17/16, directed R78 required assist of one staff for ADL's (activity of daily living), had falls, used a mechanical lift for transfers, would request toileting and required assist of one for toileting. On 10/19/16, at 7:15 a.m. R78 was lying in bed, the room was dark and quiet. On the left side of R78's bed a thin gray fall mat on the floor and on the right side a thin brown fall mat was present. A square white personal alarm was secured to the grab bar attached to the right side of R78's bed and the call light was attached to the grab bar also. On 10/19/16, at 8:19 a.m. licensed practical nurse (LPN)-A propelled R78 to the dining room in a wheel chair, the white square personal alarm was secured to the back of R78's wheel chair. On 10/19/16, from 8:27 a.m. to 8:40 a.m. R78 independently ate the breakfast meal seated in a wheel chair with the personal alarm secured to the back of his wheel chair. On 10/21/16, at 10:33 a.m. R78 was seated in a wheelchair in the hall outside of his room watching the activity of staff and other residents, the personal alarm was secured to the back of the wheelchair. A review of R78's clinical record revealed the following 8 documented falls since R78 was admitted on [DATE]: (1) 3/8/16-at 9:50 p.m. R78 was found on floor beside his bed. Resident interview indicated R78 stated,I was going to the bathroom. Staff initially placed a bed alarm. The interdisciplinary team (IDT) reviewed the fall on 3/18/16 (10 days following the fall). The post fall findings identified, Resident attempts to self transfer to BRM (bathroom). The intervention to be implemented: Placed pressure alarm. (2) 3/9/16-1:00 a.m. alarm sounded and alerted staff to R78's room. R78 was found on floor mat next to bed. R78 sustained a skin tear to the right elbow 1 cm (centimeter) by 0.8 cm. The incident note identified R78 needed to use bathroom and tried to get up. Interventions to be implemented as a result of the assessment: Bed alarm, floor mat, urinal placed. The IDT team reviewed the fall on 3/17/16 (8 days following the fall). Additional information/interventions to be communicated to staff along with changes to the care plan included: floor mat (which was currently in use and not a new intervention). (3) 3/12/16-12:30 a.m. R78 was found lying face down on floor with head against night stand. Resident interview indicated R78 had stated he was getting up to go to the bathroom. R78 sustained a laceration to the right eyebrow 2.5 cm long and a laceration to the left side bridge of his nose 0.4 cm. The incident note identified a mat was on the floor next to R78's bed, when resident got up he had bare feet and slipped on the mat. The IDT reviewed the fall on 3/14/16 (2 days following the fall). Interventions to be implemented as a result of the assessment: Resident needs a concave/lipped mattress. (4) 6/10/16-4:30 a.m. R78 was found sitting on the floor mat on floor next to bed. R78 had indicated he was going to get up and into wheel chair. The nursing assistant assisted R78 to the bathroom and to get dressed for the day. The note indicated R78 indicated he slipped on the mat by the bed was bare footed. The note indicated R78 had a problem with safety awareness, recently completed therapy and recommendations were to continue to receive help, does not comply and continues to attempt self transfer. (5) 7/15/16- 3:00 a.m. R78's fall occurred in his room and it was unknown what R78 was doing prior to the fall. The fall occurred when R78 was transferring without assistance and did not use the call light. Interventions to be implemented as a result of the assessment: Reminded to use call light and wait for assist. The nurse's notes identified R78 was found lying on floor near bed. Resident was unable to identify what he had been doing. The nurses notes also indicated the IDT reviewed the fall on 7/15/16, did not remember he should use call light to alert staff for assistance, will add a lipped mattress to bed to define perimeters. (6) 7/27/16- 6:20 p.m. R78's fall occurred in residents room and prior to the fall R78 was lying in bed. The form identified alarms had been inititated at time of fall. The note did not include an analysis of fall and had been reviewed by the IDT on 8/2/16 (6 days after the fall) (7) 9/19/16-5:20 a.m. indicated R78's fall occurred in room and prior to the fall, had been sleeping. The note faxed to the physician identified-found lying on floor in room in front of bathroom door, resident stated he had slipped. The notes indicated R78 was confused at times, forgetful and had a history of [REDACTED]. The notes lacked documentation of interventions to be implemented as a result of the fall for R78. The IDT team had reviewed the fall on 9/27/16 (8 days later) (8) 9/22/16-8:15 a.m. indicated staff were alerted to room by roommate. R78 was found sitting sideways on floor of BR (bathroom) states finished going and stood up and slipped. The note indicated R78's left shoe off and was underneath resident and right shoe falling off foot. Further, the incident note identified R78 had a have BM (bowel movement) in BR (bathroom) prior to fall. The post fall physical assessment identified R78 complained of pain with range of motion of left leg and R78's left leg was noted to be shorter than the right. The ambulance was called to transport R78 to the emergency room . R78's hospital discharge interagency referral form for readmission to the nursing home dated, 9/26/16, indicated R78 had left trochanteric fixation and nailing (surgical repair of the hip) of the left hip fracture on 9/23/16. Review of R78's Fall Risk Assessment form dated 3/7/16, identified R78 had three falls in last week, was weak, incontinent of bladder, used a walker and was able to use call light independently. Review of R78's Fall Risk Assessment form dated 6/23/16, indicated R78's assessment remained current with the following minor changes: Has had multiple falls since admission. Is reminded to use call light but doesn't. The Fall Risk Assessment forms completed failed to comprehensively assess R78's risk for falls to include but not limited to trends/patterns to falls, factors that may be causing the falls, and effectiveness of interventions. No Further Fall Risk Assessments were found in R78's record Review of R78's Bowel and Bladder Functional Evaluation Tool dated 3/14/16, revealed R78 was incontinent of urine and bowel, awoke at night to void, and was able to identify the need to void/defecate. The tool identified R78 was able to use call light, able to ask to go to the bathroom, required assist to ambulate and transfer to toilet/commode, and was able to use the toilet majority of time. The evaluation tool did not identify a toileting plan for R78. Review of R78's Bowel and Bladder Function Evaluation Tool dated 6/23/16, identified R78 was continent of bowel and was incontinent of urine 1-2 times weekly. Review of R78's Resident Referral Interdepartmental Communication forms between nursing and physical therapy revealed the following: - 4/1/16, Physical Therapy-Please encourage Pt. (patient) to transfer and toilet with stand-by-assist only. We are working towards independent transfers and getting rid of alarm. Any? (questions) call. Nursing responded on 4/6/16- Cont (continue) with alarm for now. SBA (stand by assist) and encourage him to do himself. Working on getting back up breaks. -5/8/16, Physical Therapy-Pt. (patient) has been D/C (discharged ) from therapy please ambulate with RW (regular walker), transfer belt and SBA, 2 x (times) daily Pt. amb 600 feet without difficulty. The form included a nurses signature, however, lacked any response to the communication from therapy. Review of R78's undated Pro Rehab Nursing Referral For Therapy Screen form indicated R78 had been demonstrating independence in transfers and ambulation, alarms had been removed and nursing had requested a therapy screen. The form included documentation from therapy personnel, signed on 6/24/16, which directed that R78 was able to complete transfers and ambulation with SBA at day of discharge from therapy. R78 remained assist of one due to issues with safety awareness. The therapy note recommended R78 remained assist of one. Review of R78's Nursing Quarterly ADL assessment dated [DATE], identified R78 had Alzheimer's, and a history of falls. The assessment identified R78 had moderately impaired cognitive skills for daily decision making, decisions poor, cues/supervision required, and required limited assistance with transferring and walking and supervision with toileting. On 10/19/16, at 1:17 p.m. a review of R78's fall reports and progress notes was conducted with the assistant director of nursing (ADON) present. The ADON verified R78's multiple falls, although was unsure what interventions were currently in place. The ADON identified following a resident's fall the post- fall clinical team which included nursing, the administrator and social services, reviewed the facility form titled Fall Risk Post- Fall Assessment. The form was initiated by the floor nurse when resident falls occurred and the team reviewed for appropriate interventions. The ADON indicated R78's fall reviews were difficult to interpret what interventions were initiated following the falls. The ADON indicated she believed the falls were fully assessed and appropriate interventions were initiated for R78's falls. ADON confirmed R78 had sustained a hip fracture after the fall on 9/22/16. Review of R78's progress noted dated 3/10/16 to 9/22/16, included various notes which identified R78 received assistance with ADLS, transfers, and self transferred at times. The progress notes included: -5/18/16, Did a four day trial of alarms off resident. Resident did well, toileted self, transferred bed/chair/wheelchair without incident Removed alarms at this time. - 7/24/16, found on knees in front of closet,minimal one person assist up. -9/19/16, R78's roommate alerted nurse R78 was on the floor. R78 found on his back, on the floor in front of the bathroom door, trying to sit up. R78 stated he must of slipped on something, gripper socks on. -9/22/16, R78 found on floor in bathroom, sitting on buttocks and stated went to bathroom, finished, stood up and fell , slipped. Complained of much pain left hip with internal rotation, shortening of left leg. Ambulance called to transport. The note indicated R78 had sustained a fractured hip and would probably have surgery the following day. On 10/20/16, at 10:11 a.m. nurse manager (NM)- B stated she felt the lack of sufficient staffing in the facility must have something to do with the large amount of resident falls in the facility. On 10/20/16, at 10:45 a.m. nursing assistant (NA)-I indicated R78 was independent to go to the bathroom by himself prior to the fall and indicated since R78's hospital stay he needed assistance to go to the bathroom. NA-I indicated R78 did not always remember to check if the wheel chair brakes were on and now had brakes on the wheel chair that locked automatically. On 10/21/16, at 1:31 p.m. NA-B verified R78 had a recent decline because of a fall with fractured hip. NA-B verified R78's frequent falls were usually related to going to the bathroom or when coming back from the bathroom. NA-B stated she felt R78 was independent to take himself to the toilet prior to the fall and would turn the call light on for assistance when needed to pull up his pants or to shave. NA-B identified R78 at times used the call light appropriately and other times did not. NA-B indicated a toileting program may have been beneficial for R78 prior to his fall with a fractured hip. On 10/21/16, at 2:13 p.m. NA-J indicated R78 was independent with dressing, hygiene and toileting before the fall and hip fracture. NA-J identified prior to the hip fracture R78 was always trying to go to the bathroom. On 10/21/16, at 2:39 p.m. NA-A indicated she/he did not work often with R78 and stated, He will be sitting in the hall and say 'hey', have to go to the bathroom and staff would assist him. On 10/21/16, at 2:49 p.m. NM-B indicated prior to R78's fall resulting in a fracture, R78 required assistance of one to transfer and remind R78 to ask for help to toilet because he was reluctant to ask or did not ask for help. NM-B indicated R78's toileting program was to sound call light when he needed to go to the bathroom or he attempted to transfer himself. NM-B stated, He (R78) calls or transfers self when he needs toilet. NM-B reviewed the 8 falls and interventions. After review of the falls, NM-B stated she felt there had been a pattern of the falls was going to or coming off of the toilet. NM-B confirmed R78 was not on a toileting program and stated, It may have been a good idea. On 10/21/16, at 3:07 p.m. a follow up interview with the ADON verified prior to R78's hospitalization the facility had not initiated a toileting plan for R78. The ADON felt R78's falls had been assessed, and appropriate interventions had been in to place. ADON stated had not identified a pattern with R78's falls, however, indicated evaluation for a pattern for falls was not part of the comprehensive assessment for R78. On 10/24/16, at 2:00 p.m. nurse practitioner (NP)-A indicated she expected the facility staff to assess falls routinely and attempt to identify a pattern or reason for the falls in an attempt to minimize further falls. On 10/24/16, at 4:17 p.m. a phone interview with R78's physician (MD)-A verified he was aware R78 had a fall which resulted in a fractured hip, however, was unaware of the number of falls. MD-A indicated R78 was demented and was not easily redirected. MD-A verified he would expect facility nursing staff to assess the falls and if going to the bathroom is the common reason with the falls, he would expect staff to provide an appropriate intervention related to R78's toileting needs. The requested facility policy regarding facility falls was not provided.

Based on observation, interview and document review, the facility failed to provide the necessary care and services related to pressure relieving devices for 3 of 4 residents (R70, R47, R17) reviewed for pressure ulcers. This deficient practice resulted in actual harm for R70 identified with a reoccurring stage 2 pressure ulcer to the spine. Findings include: R70's significant change Minimum Data Set ((MDS) dated [DATE], identified R70 had [DIAGNOSES REDACTED]. The MDS identified R70 had moderate cognitive impairment, and required extensive assistance with transfers and bed mobility. Further, the MDS identified R70 was at risk for development of pressure ulcers, and did not have a current pressure ulcer. R70's Care Area Assessment (CAA) dated 10/13/15, identified R70 had risk factors for development of pressure ulcers of immobility, incontinence, cognitive loss and altered mental status and required a special mattress or seat cushion to reduce or relieve pressure. The CAA identified R70 required extensive assistance with all areas, was at risk for development of pressure ulcers related to mobility needs and incontinence, standard repositioning assist provided and would address pressure ulcer risk with care plan. R70's Braden Scale (tool utilized for predicting pressure sore risk) dated 10/7/15, identified R70 had slightly limited sensory perception, was chairfast, very limited mobility, potential for friction and shear and identified R70 was at high risk for development of pressure ulcers. R70's care plan revised 10/21/15, indicated R70 had a self care deficit related to kyphosis, [MEDICAL CONDITION], anxiety and mobility impairment. R70's care plan identified R70 had a history of [REDACTED]. May also present as a intact or open/ruptured serum filled blister) on mid spine and was at risk for further breakdown. R70's care plan identified she required assistance of a pivot transfer device or with a mechanical lift for transfers and was to be repositioned every 2 hours as the resident was unable to reposition independently. Further, R70's care plan directed staff to utilize a pressure relief cushion in chair, a sheep skin to the back of the chair and a sheep skin in bed. On 11/17/15, at 4:43 p.m. the assistant director of nursing (DON) stated R70 had a current stage 2 pressure ulcer on her spine. On 11/17/15, at 6:05 p.m. R70 was observed seated in the Broda wheel chair (high backed specialty wheel chair) with her back rounded forward, and neck extended forward and to the right, both arms rested on the table in the facility dining room. R70's rounded back rested directly on the maroon colored, vinyl back of the wheelchair, without a sheep skin pad in place on the back of the chair. At 6:20 p.m. R70 remained seated in the Broda wheel chair in the dining room, eating her supper meal. R70's back continued to rest directly on the back of the wheelchair with out sheep skin on the back of the chair between R70's kyphotic back and the wheel chair back. R70 remained in the wheel chair, with her back resting directly on the vinyl back of there wheelchair, with out the sheep skin on the back of the chair through out the evening meal service. On 11/18/15, at 9:16 a.m. R70 was observed in her room, seated in the Broda wheel chair with R70's back resting directly on the vinyl back of the wheelchair. R70 did not have a sheep skin pad in place on the back of the wheelchair, and was not observed on any portion of the wheelchair. During observations on 11/19/2015, at 7:19 a.m. R70 was observed in her room, listening to country music on the television. R70 was seated in the Broda wheel chair with her back resting directly on vinyl back of the wheelchair. R70 did not have a sheep skin on the back of the chair. -At 7:32 a.m. nursing assistant (NA)-M entered R70's room and assisted R70 out of her room to the dining room. R70's back rested directly on the vinyl back of the wheelchair. -At 8:01 a.m. R70 remained seated at the table with the breakfast meal in front of her. -At 8:17 a.m. R70 remained seated at the table. -At 8:25 a.m. R70 remained seated in the Broda wheel chair in the dining room. Licensed practical nurse (LPN)-A was seated next to R70, and assisted R70 to eat the breakfast foods. -At 8:38 a.m. R70 was assisted by facility staff to her room to sit in front of the television. R70 remained in the Broda wheel chair, the back of the chair had been partially reclined, the sheep skin was not on the back of the wheel chair to relieve pressure on R70's back. -At 9:06 a.m. R70 remained in the partially reclined Broda wheel chair. R70 did not have the sheep skin pad in place during the entire continual observations from 7:32 a.m. to 9:06 a.m. During observation on 11/20/2015, at 12:16 p.m. R70 was seated in the Broda wheel chair at a table in the dining room. R70's back rested directly on the vinyl back of the wheelchair, with out sheep skin in place on the back of the wheelchair. At 12:39 p.m. R70 remained seated in the Broda wheel chair, with out sheep skin for pressure reduction on her back, eating her meal. On 11/23/2015, at 10:01 a.m. NA-C stated R70 utilized a sheep skin blanket on R70's bed because of a sore on R70's back. NA-C verified she cared for R70 often, including the prior week. NA-C indicated it was not the usual practice to place the the sheep skin blanket behind R70's back when seated in the wheel chair. NA-C indicated she had not placed the sheep skin blanket behind R70's back in the Broda wheel chair when caring for R70. NA-C stated, No one told me to do it. On 11/23/2015, at 1:45 p.m. the director of nursing (DON) verified a protective dressing was used on R70's back due to a history of pressure ulcers in that area related to R70's kyphosis, and the sheep skin blanket was to be used in the wheel chair and in bed. She confirmed R70's care plan and nursing assistant sheets were a guide/directive for R70's care. The DON stated she would expect these interventions to be followed for R70 to prevent skin break down. Review of the untitled form, identified by facility as the nursing assistant care sheet, listed various interventions which included to pivot or utilize a standing lift for transfers, reposition every 2 hours and as needed, use of a Broda chair and to sit in recliner during day with sheepskin on and use it in bed too. The care sheet did not address the use of a sheep skin on the back of the Broda chair. Review of R70's nurse progress notes reviewed from 10/21/15 to 11/12/15, revealed the following: - 10/20/15, O/A (open area) superficial same recurrent area mid spine. Using sheep skin padding and in Broda chair for positioning. -10/21/15, O/A to spine-has kyphosis-using sheep skin to area-recurrent area in past has been resolved with use of sheep skin. Will use Allevyn for healing and ongoing pressure relief. Further, the note identified staff would check with therapy if a cushion available to put behind back -10/24/15, Allevyn intact to spine. Up per usual. Using sheep skin -Broda chair repositioned. -11/4/15, Allevyn changed to Opti Foam dressing. Area continues to be open, flat and light pink -11/10/15, continue with deep red area, unopened, some peeling skin with closed tissue underneath. Sheep skin down in bed. -11/11/15, Area to mid spine assessed-2.0 x 0.8 cm superficial open area-scant amount of serous sanguineous drainage cont. (continue ) with tx (treatment) per MD orders-sheep skin to bed and back of Broda chair. -11/12/15, Drsg (dressing) changed to mid spine. More red than when seen 11/10. Same measurements as 11/11. Review of R70's Wound Care Flow Sheets from 9/17/15 to 11/20/15, revealed the following: -9/17/15, an open area on the mid spine measured 0.5 cm -9/29/15, open area resolved. -10/20/15, open area on the mid spine measured 1 cm -11/8/15, area resolved. -11/10/15, mid spine not an open ulcer, deep pink in color and measured .1 cm by .8 cm -11/11/15, open area on mid spine measured 2 x 0.8 cm -11/17/15, open area measure 2 cm by 0.8 cm with tail to the right of the middle which measured .2 cm. The flowsheet listed a red area around the open area which measured 3.8 cm -11/20/15, open area measured 0.2 x 0.8 cm On 11/23/2015, at 2:13 p.m. NA-G verified R70 utilized a sheep skin pad and stated the sheep skin pad was used only when R70 was in bed. NA-G indicated she occasionally placed the sheep skin in the seat of the reclining chair in her room. NA-G stated, I think it keeps her warm. NA-G indicated R70's Broda chair and stated, No I don't ever put it in that chair. During observations on 11/23/2015, at 2:05 p.m. R70 was lying bed, with a sheep skin pad in pad under R70 back. The director of nursing (DON) assisted R70 to move to her side and removed a light beige dressing from R70's bony prominence over the mid spine area. R70 was observed to have an open area with irregular edges on the mid spine areas and light brown colored drainage was noted on the inside surface of the foam dressing which had been removed from the open area. At 2:16 p.m. the DON confirmed the stage 2 pressure ulcer, measured the open area and indicated the open area measured 1.7 cm by 0.8 cm. At 2:23 p.m. the DON verified the open area was not a new problem and stated, The wound heals and then opens. On 11/23/2015, at 2:38 p.m. NA-L verified sheep skin was placed behind R70's back only when in bed and the sheep skin was not used in the wheel chair. On 11/23/2015, at 2:39 p.m. NA-F indicated sheep skin was used only when R70 was in bed, not when in the wheel chair. On 11/23/2015, at 3:18 p.m. the DON confirmed the current facility policy. She confirmed R70 had reoccurring stage 2 pressure ulcers on her mid spine due to her bent spine, back and neck. The DON verified the sheep skin blanket was initiated due to R70's history of reoccurring pressure ulcers and was to be utilized to heal and prevent the development of further pressure ulcers. On 11/23/15, at 5:10 p.m. R70 was seated in the Broda chair in her room. R70's rounded back rested directly on the vinyl back of the wheelchair, no sheep skin was observed on the back of R70's wheelchair. On 11/23/2015, at 5:12 p.m. R70 stated she was not aware of ever having the sheep skin blanket in the wheel chair. R70 indicated she would like to try the sheep skin on the back of the wheel chair. On 11/23/2015, at 5:17 p.m. pool staff licensed practical nurse (PLPN)-G verified R70 was seated in the Broda chair with out sheep skin behind R70's back. PLPN-G indicated she did not know if the sheep skin should be used in R70's wheel chair or not. On 11/23/15, at 5:35 p.m. the DON stated the use of the sheep skin in R70's Broda chair was to heal and prevent further development of pressure ulcers. She stated she had considered cutting the sheep skin utilized on R70's bed in half to use in the Broda chair, so staff did not have to move the sheep skin back and forth but had ordered a separate sheep skin for the Broda chair instead. R47 was totally dependent on staff for cares, did not ambulate, and identified at risk for development of pressure ulcers. R47's care plan was not updated to reflect appropriate interventions to prevent pressure ulcers. R47's Order Summary Report dated 10/8/15, identified R47 had [DIAGNOSES REDACTED]. R47's quarterly MDS dated [DATE] identified R47 had severely impaired skills for daily decision making, was totally dependent on staff for activities of daily living (ADLs) and did not ambulate. Further, the MDS identified R47 was at risk for the development of pressure ulcers. R47's care plan revised 6/1/15, identified R47 was at risk for alteration in skin integrity related to decreased mobility and incontinence of bowel and bladder. Interventions to be implemented included heel protectors when in bed, cushion in Broda wheelchair and routine diabetic foot care. Review of R47's quarterly ADL assessment, dated 9/21/15, revealed R47 had severely impaired skills for daily decision making, was totally dependent in mobility, utilized a full body lift and a Broda chair. Review of R47's Braden scale dated 5/29/15, and 9/3/15 identified R47 was at high risk for the development of pressure ulcers. Review of R47's Review of Tissue Tolerance form, dated 9/21/15, identified R47 was a very high risk for skin breakdown, utilized a alternating pressure pad, was on an every 2 hour repositioning schedule, and to continue with current plan of care. Review of R47's physician orders [REDACTED]. During observations on 11/19/2015, at 8:12 a.m. R47 was propelled by house keeping staff (HK)-A, in the Broda wheel chair to the dining room. R47 was seated in Broda chair, and wore tan stockings with no shoes or slippers on her feet. R47's right foot rested flat on bottom of the foot rest with heel resting on the back of the foot rest, and R47's left knee was bent with the heel on back of the wheel chair foot rest. Both of R47's heels were not offloaded. At 8:15 a.m. R47 was assisted to eat, heels remained resting directly on the foot rests of the wheel chair. At 8:48 a.m. R47 was seated in the Broda wheelchair in her room. R47's feet remained in the same position with heels pressed against the back of the wheel chair foot rest. At 8:53 a.m. R47 remained in room with room mate and a unit worker. R47's feet remained in the same position with heels pressed against the back of the wheel chair. At 9:14 a.m. R47 remained seated in her Broda wheel chair reclined partially. R47's feet remained with the heels pressed against the back of the wheel chair, a quilted quilted lap blanket lay across R47's lap and hung down to the top of R47's ankles. At 9:57 a.m. R47 remained seated in her Broda wheel chair, heels pressed to the back of the wheel chair. At 10:26 a.m. NA-O and NA-I assisted R47 from the wheel chair to the bed with a full body lift. NA-O and NA-I confirmed R47's heels had rested directly on the wheelchair, until they assisted her to transfer to bed. NA-O and NA-I both indicated they was not aware R47's care plan directed to float both heels while in the chair. On 11/19/2015, at 10:38 a.m. LPN-C stated, (R47's) heels should actually be free floated. LPN-C verified R47 normally did not wear shoes and should have had her heals free floated. On 11/19/2015, at 10:50 a.m. clinical manager (CM)-A verified R47 was at risk for skin break down and pressure ulcers. CM-A verified R47's feet should have been floated when seated in the wheel chair to prevent heels from pressing on the back of the wheel chair. On 11/19/2015, at 1:51 p.m. CM-A reviewed R47's skin assessments and current care plan. CM-A indicated the care plan had not been updated and was not current regarding repositioning and skin needs. CM-A indicated the care plan should have included floating R47's heels. CM-A stated,we are behind on updating care plans. CM-A verified R47's care plan had not been updated for repositioning needs since 2013. R17's significant change MDS dated [DATE] identified R17 had severe cognitive impairment, was totally dependent on staff for all activities of daily living (ADLs) except for eating. The MDS further identified R17 had [DIAGNOSES REDACTED]. R17 was identified to have 2 existing stage 2 pressure ulcers, and was at risk for developing further pressure ulcers. R17's MDS identified skin and ulcer treatments which included a pressure reducing device in R17's wheelchair chair and bed, and pressure ulcer care and dressings. The MDS did not identify R17 was on a turning and repositioning program. R17's significant change Care Area Assessment (CAA) dated 9/21/15 identified R17 had developed 2 stage II pressure ulcers as blisters to both heels. R17's pressure ulcer risk factors included immobility, altered mental status, poor nutrition and incontinence. The CAA also identified R17 required pressure relief, but failed to identify R17 required staff assistance to relieve pressure over any one site or that R17 required a regular turning schedule. R17's care plan dated 10/21/15 identified staff were to anticipate R17's needs and R17 required total assistance to turn and position himself in bed. The care plan further identified R17 had a stage 2 pressure ulcer to his right heel, utilized a gel cushion in his wheelchair, a pressure reducing mattress on his bed, was to wear protective boots or staff were to free float his heels when he was in bed. R17's Braden scale, dated 5/1/15, identified R17 was at low risk for development of pressure ulcers. R17's Braden Scale, dated 9/15/15, identified R17 was at high risk for development of pressure ulcers. R17's Tissue Tolerance Test (TTT), dated 5/1/15, identified no areas of concern and R17 would continue to utilize a gel cushion in his wheelchair. R17's TTT dated 9/15/15 identified R17 required turning and positioning every 2 hours, gel cushion to his wheelchair and boots on both feet due to blisters to heels. Review of R17's Wound Care-Skin Integrity Evaluation form, dated 11/12/15, revealed R17 had a pressure ulcer at the right inner calcaneus full thickness, unstageable pressure ulcer, 1.5cmx1cm with wound depth unable to determine, serous drainage, wound bed 70% slough, 30% granulation, fragile peri-wound. On 11/19/15 from 7:28 a.m. to 7:58 a.m. R17 was observed in bed asleep on his back with both heels resting directly on the mattress of his bed. R17 wore red gripper socks on both feet, and did not have protective boots on his feet. R17's protective boots were not observed to be in his room. NA-B and NA-C entered R17's room to complete morning cares. During cares R17's heels remained on the bed and were not floated. R17's same gripper socks were left on both feet and NA-B struggled to get his regular slippers on over his thick gripper socks. NA-B confirmed R17's slippers were difficult to get on and were too tight because of his gripper socks. On 11/19/15, at 10:33 a.m. R17 was observed asleep in his wheelchair in front of the nurses station. R17 wore red gripper socks under his regular slippers. R17's right heel was resting directly on the floor. On 11/19/15, at 1:01 p.m. R17 was observed propelling himself in his wheelchair using only his right arm and right foot. R17 pushed off the floor with his right heel to propel himself forward in his chair. On 11/20/15, at 9:03 a.m. R17 was observed self propelling in his wheelchair using only his right arm and right foot. R17 pushed off the floor with his right heel to propel himself down the hallway. On 11/20/15, at 9:10 a.m. R17 continued to propel his wheelchair and had both feet on the left foot pedal. R17's feet were stacked and heels rested directly on the foot pedal. On 11/19/15, at 1:29 p.m. NA-C and NA-B stated they were not sure if R17 had any open areas and indicated they did nothing special for skin care for R17. On 11/19/15, at 1:36 p.m. ADON stated R17 had a current stage 2 pressure ulcer on his right heel. She stated R17's pressure ulcer interventions were an air mattress on his bed and a cushion in his wheelchair. She indicated staff were directed to utilize protective boots and float his heels. She confirmed R17 should have boots on or his heels floated when he is in bed and both at the same time would be great. She stated R17 might be on a turning and repositioning program but she wasn't sure. She stated on 9/4/15 R17 had fluid filled blisters on both heels and interventions initiated at that time were floating heels when in bed and boots on all the time. She stated his ulcers were left open to air and were to be monitored every shift. She confirmed R17's care plan and skin interventions were gel cushion to wheelchair, boots on in bed, free float heels in bed and an air mattress on bed. She stated she would expect the staff follow R17's care plan and float his heels and apply his boots when he's in bed. She stated she felt staff knew what they were supposed to do for R17's skin, and confirmed that floating R17's heels and the boots on in bed were not identified for staff on their daily care sheets. On 11/19/15, at 4:10 p.m. NA-D stated other than using wheelchair foot rests they didn't do anything special for R17's skin or feet. On 11/19/15, at 4:15 p.m. NA-E stated R17 used to have a bloody blister on his heel, and the heel sores come and go. He stated R17 was supposed to wear the boots on his feet and his heels were supposed to be floated at all times when he is in bed. On 11/19/15, at 4:20 p.m. NA-F stated she was not aware R17 had any skin problems. She stated other than putting lotion on him, she didn't do anything else for his skin. On 11/20/2015, at 5:03 p.m. ADON applied a new dressing to R17's pressure ulcer. R17's skin on the heel appeared very shiny, fragile and pink. The purple area on the bottom back of R17's heel measured 2.5cmx2.5cm, no open areas were seen. R17's left heel was pink in color, no open areas seen. During continuous observations on 11/23/15, at 7:16 a.m., R17 was lying on his right side in bed, with both heels resting directly on the mattress of the bed R17 was not wearing protective boots and his heels were not floated. R17's dressing to his right heel was visible and a pillow was observed behind R17's left foot. -7:43 a.m. R17's body and heel position had not changed. -8:20 a.m. R17's body and heel position had not changed. -9:04 a.m. DON briefly entered R17's room, and then exited into the hallway. R17's heels were on the bed with the right foot and heel uncovered and resting on bed. The DON was not observed to offer repositioning, floating the heels or application of the protective boots and did not offer to reposition R17. DON did not provide any interventions and left R17's room. -9:36 a.m. medical records (MR)-A, NA-L and CM-B entered R17's room to help him get up to eat. CM-B confirmed R17 did not have his protective boots on and his heels were not floated by pillows, but should have been. She stated she felt his heels were not floated because he is so active. She stated she didn't think R17 was on repositioning program because she felt he was out of bed so much. R17's heels had not been floated, not worn protective boots on both heels and not been repositioned from 7:16 a.m. to 9:36 a.m., a total of 2 hours and 20 minutes. On 11/23/15, at 10:00 a.m. CM-B confirmed R17's care plan directed the use of protective boots and floating heels were included on his care plan. She indicated she would expect staff to complete these interventions consistently. She stated she was unsure if R17 was supposed to be on a turning and repositioning program. She stated she didn't know why his boots weren't on or his heels weren't floated. On 11/23/15, at 2:00 p.m. NA-C stated she was not aware R17 was supposed to have protective boots on in bed or to float his heels. On 11/23/15, at 2:01 p.m. NA-L stated she felt R17 was supposed to wear boots in bed and float heels, but wasn't sure why it had not been done. On 11/23/15, at 2:18 p.m. CM-B stated R17 was supposed to be repositioned every 2 hrs as needed. She stated when facility staff make rounds they would reposition him if R17 hadn't been moving around in bed. She stated she would not expect R17 to be on a turning and repositioning schedule because he had an air mattress on his bed and he moved around a lot. She stated it didn't surprise her that staff were not aware R17 was supposed to wear protective boots or that his heels were to be floated. She stated staff have been educated on looking at individual resident care plans and the boots and heel floating should be on R17's care plan. She stated she would expect R17 to wear the boots and have his heels floated while he is in bed. On 11/23/15,at 2:51 p.m. DON confirmed R17's current care plan. She stated R17 had an air mattress on his bed and his heels were floated when he was in bed. She stated she felt she wasn't sure if R17 needed both. She stated she was not aware R17 hadn't been repositioned for 2 hours and 22 minutes this morning, and that his heels weren't floated and he was not wearing protective boots. She stated R17's care plan did not list a repositioning schedule and stated it was he moved around. Review of R17's Nurses Notes reviewed from 9/4/15 to 11/19/15 revealed the following -9/4/15 blisters to both heels, right heel blister 1.5cmx2cm, left heel blister 3cmx2cm. Pressure relieving boots placed. -9/5/15 blisters intact, pressure relief. -9/7/15 R17 wearing pressure reducing boots at all times, pillows to float heels. -9/11/15 blister to right rubbed off and was open. Dressing applied after cleansed. Pressure relieving boots on -9/13/15 right heel and left heel both had thin brown scabs. -9/14/15 right heel blister was open and dark. -9/16/15 pressure reducing boots not on, heels floating on pillows. -9/18/15 right heel had soft dark purple area, not open 2.5cmx2.5cm, left heel blister resolving, open to air. Pressure relief boots on in bed, encourage to free float heels. -9/22/15 heel blisters scabbed over and dry. R17 refusing to leave boots on, heels floated in bed -9/23/15 left heel not open, hardened-callous like area. Right heel had 3cm circular, soft eschar-like area. R17 was wearing non-skid slippers on and both heels were resting directly on bed. R17 was not wearing boots and heels not floated. -9/28/15 right heel dark purple-brown 2.5cmx2.5cm area, left heel 3.0cmx2.0cm dry light brown scab, not open. -10/8/15 right heel dark base, moist, left heel healed -10/14/15 right heel dark area 1.2cmx1.2cmx0.1. Continue air mattress, pressure relief boots, turning and repositioning by staff, magic cups. -10/21/15 right heel remained open, wound base pink, moderate amount of yellow drainage, continue air mattress to bed, turning and repositioning by staff, pressure relief boots on in bed or float heels if he kicks his boots off. -11/12/15 right inner calcaneous wound assessed. -11/19/15 dressing change to right heel done, slight odor to the area noted. Facility Pressure Ulcers/Skin Integrity/Wound Management Policy dated 9/13/11 identified a pressure ulcer is avoidable when a resident develops a pressure ulcer because the facility did not effectively evaluate the resident's clinical condition and pressure ulcer risk factors, define and implement interventions consistent with resident needs, goals and standards of practice, or monitor and evaluate the impact of interventions and/or revise interventions as appropriate.

Based on observation, interview and document review, the facility failed to consistently provide supervision and interventions for ventilator dependent residents resulting in death for 1 of 4 (R1) residents that required a ventilator for respiratory support. Staff failed to promptly respond to a ventilator alarm when the tubing became disconnected from R1's ventilator for an extended period of time and R1 was found deceased . This failure had the potential to affect an additional 2 residents (R2, R3) that required continuous ventilator support and 1 resident (R4) who required ventilator support at night. The immediate jeopardy began on [DATE], when the facility failed to provide R1 with supervision and respond to the resident's ventilator alarm for greater than 6 minutes. R1 was found deceased with the ventilator tubing disconnected from the respirator. The immediate jeopardy was identified on [DATE]. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 2:50 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], at 5:52 p.m. when the facility implemented a system to remove the immediate jeopardy that included: 1) Immediate education of the evening shift to respond immediately to resident's rooms when a ventilator alarm was sounding and notify the licensed nurse by using a hand held radio. 2) At the beginning of the night shift the staff received the following education: a) The licensed nurse responsible for the nursing unit B (unit with the ventilators) would notified the nursing unit A wing licensed nurse when taking a break to ensure availability during emergencies. b) Licensed nurses were to take breaks when the NA's had finished their rounds with the residents. c) NA's were educated to respond immediately to ventilator alarms. d) When the licensed nurse on nursing unit B was on break, the NA's would report any concerns to the nursing unit A nurse using the hand held radio to ensure a prompt response. 3) All nursing staff would carry radios in order to communicate and call for assistance as needed. The radio charging stations were to be located at both nursing stations A and B. Prior to removing the immediate jeopardy, the administrator had purchased and educated the evening staff on the use of the radio (walkie-talkie). 4) The administrator, DON, and assistant DON (ADON) would be in the facility throughout the weekend to educate and train weekend staff on the above listed changes. Following the removal of the immediate jeopardy, noncompliance remained at the lower scope and severity, of isolated actual harm that was not immediate jeopardy. Review of the facility's investigative report dated [DATE], revealed on [DATE], at approximately 3:05 a.m. licensed practical nurse (LPN)-A had returned to the nursing unit B following her break off the unit. At that time, LPN-A heard a ventilator alarm sounding. Nursing assistant (NA)-C was at the nursing unit desk B and indicated to LPN-A that R4's ventilator alarm was sounding. LPN-A checked and R1 not R4's ventilator alarm was sounding. At 3:05 a.m. upon entering R1's room, LPN-A observed the tubing leading from the ventilator to R1 [MEDICAL CONDITION] was disconnected with R1's right arm laying over the tubing. R1 had no pulse and pupillary (pupils) responses. At 3:05 a.m. R1 was pronounced dead. Review of R1's medical record revealed R1's [DIAGNOSES REDACTED]. to breath without ventilator support. Because of that diagnosis, R1 was ventilator dependent for breathing since [DATE]. R1 also had a history of [REDACTED]. Upon R1's admission to the facility, R1 choose not to be resuscitated if R1 had a respiratory or [MEDICAL CONDITION] (not breathing and no pulse). Review of R1's plan of care in place at the time of the [DATE] incident, revealed R1 was unable to speak due to the [MEDICAL CONDITION] (an opening through the resident's neck into the trachea where a tube was placed to provide an airway to the lungs) and ventilator. Staff were to anticipate R1's needs, encourage a communication board, and non-verbal communication. Staff were to ask questions that had a yes/no response and occasionally R1 could point at objects or mouth words. The care plan established R1 was dependent on the ventilator, was alert and oriented. An area added to the care plan and not dated, stated, R1 had an alteration in cognition related to tactile and visual hallucinations (R1 frequently would see and feel bugs mostly at night). To lessen the hallucinations, R1 preferred to sleep with a towel over his head at night. R1 was dependent on staff for turning and repositioning and required assistance from two staff and a mechanical sling lift for transfers and staff assistance with incontinence care every two hours. R1 took nothing by mouth and was fed with tube feedings. Care planned interventions for the ventilator and [MEDICAL CONDITION] care included suctioning the [MEDICAL CONDITION] as needed (usually 1 time a shift), ventilator checks every 3 hours and as needed, changing the ventilator tubing weekly, oxygen saturation levels every shift, licensed staff to check the [MEDICAL CONDITION] cuff for proper inflation every shift, and a RN to change the [MEDICAL CONDITION] every month. R1's physician orders [REDACTED]. The oxygen was to be kept at 0 to 5 liters to keep the oxygen saturation level > 92 %. The orders indicated R1 received [MEDICATION NAME] (anti-anxiety medication) 1 mg (milligrams) in the morning and 0.75 mg mid-day and at bedtime with 0.5 mg every 2 hours as needed for anxiety. Review of the facility's Ventilator Check Sheet form for R1 dated [DATE] through [DATE], completed by licensed staff every 3 hours, revealed R1's respiratory rate was normally with the respirator setting at 12 breath per minute and approximately three to five times a day was 13 to 17 breaths per minute (3 to 5 breaths above the respirator setting). The Medication Administration Record [REDACTED]. Review of the facility's Daily Behavior Observation Tool from [DATE] to 24, 2013, revealed R1's target behaviors identified by the facility included: anxiety with shortness of breath related to ventilator use, fearfulness of not getting air, and hallucinations. The tool established R1 had 1 to 3 episodes a day of shortness of breath related to the ventilator use. The interventions documented included calm reassurance, redirection, and [MEDICATION NAME]. R1's MAR from [DATE] until [DATE], revealed in addition to the scheduled [MEDICATION NAME], R1 had requested as needed [MEDICATION NAME] from one to three times a day for complaints of shortness of breath. R1's shortness of breath was relieved with the [MEDICATION NAME]. The nurse practitioner progress note dated [DATE], indicated R1 was started on Z-Pak (antibiotic) 500 mg one time and 250 mg four additional days on [DATE], for increased lung congestion and thick white/yellow secretions suctioned from the [MEDICAL CONDITION]. A sputum culture was obtained which was positive for pseudomonas (bacteria) and the antibiotic was changed to [MEDICATION NAME] (sensitive to pseudomonas) 500 mg every day for 7 days. The last dose of [MEDICATION NAME] was administered to R1 on [DATE]. R1 refused hospitalization and preferred to be medically managed at the facility. Staff were to notify the physician with any acute (sudden) changes in R1's respiratory status and/or a temperature above 99.6 degrees Fahrenheit. The note established R1 had a history of [REDACTED]. The note indicated R1's respiratory status had continued to improve with the antibiotic. A nursing progress note dated [DATE], at 12:30 a.m. revealed R1 had received a scheduled nebulizer treatment and was suctioned for thick green/yellow sputum with continued complaints of shortness of breath. R1 was given [MEDICATION NAME] 0.5 mg and suctioned again for a large amount of clear/green sputum with relief of R1's anxiety and shortness of breath. The nursing progress note dated [DATE], at 2:30 a.m. indicated staff had checked R1 who was awake and indicated to staff that his breathing was improved. R1's oxygen saturation was 98 % at 4 liters of oxygen. The nursing progress note dated [DATE], at 3:05 a.m. revealed LPN-A heard R1's ventilator alarm sounding and checked on R1. R1's ventilator tubing was under R1's right arm and disconnected. R1 had no pulse, the right anticubital area (elbow) was mottled, facial color was ashen/gray, and the pupils were dilated and fixed. RN-B completed an assessment and pronounced the resident's death. At 3:20 a.m. the DON, family, physician, and funeral home were contacted of R1's death. On [DATE], observations were made of the facility. The facility's floor plan was square shaped with a tail at one end of the square (similar to a P shape) that created on long hallway. Nursing unit desk A was located at the top corner of the square and at the beginning of the tail that created a long hallway. The nursing unit desk B was at the lower portion of the square (same side of nursing unit desk A) located at the middle of a long hallway (that was created by the tail). The rooms of the 4 residents that required ventilator support were located at the lower portion of the square and at the middle portion of the long hallway, all near nursing unit desk B. On [DATE], at 10:30 a.m. the distance was measured with the maintenance director from the nursing unit desk B to R1's room which was 30 feet. Interview with the DON on [DATE], at 9:36 a.m. established the night shift (10:00 p.m. until 6:30 a.m.) was staffed with two licensed nurses, one assigned to nursing unit A and one assigned to nursing unit B. In addition, two to three NAs were scheduled on the night shift. Usually there was one NA on nursing unit A and one NA on nursing unit B. On [DATE], the night of the incident, there were two licensed staff and two NA's working the night shift. Interview with NA-C on [DATE], at 9:45 a.m. established on [DATE], NA-C had been completing rounds (checking on residents) in resident rooms when LPN-A left nursing unit B for her break (unable to indicate time). NA-C said she started rounds at approximately 2:30 a.m. and R1 was the fourth resident she had assisted with cares. NA-C said she had assisted R1 with incontinence care and repositioning and R1 was awake during cares. Prior to leaving R1's room, NA-C said R1 was repositioned on his/her back and she placed the call light in R1's hand, clipped the light to R1's gown, placed the towel over R1's face as requested by R1, and placed the ventilator tubing down the center of R1's chest. NA-C said she finished rounds and sometime before 3:00 a.m. returned to nursing unit B desk, NA-C said she heard a ventilator alarm sounding in the hallway when she returned to the nursing unit desk B. NA-C checked on R4 (room across the hall from R1) who was asleep and went back to the nursing unit desk B. NA-C did not check R1. NA-C said she heard the alarm sound for approximately 5 minutes. NA-C said she had not been trained by the facility to reconnect ventilator tubing or to respond to ventilator alarms. NA-C said the licensed nurses always responded to the ventilator alarms. NA-C did not attempt to contact RN-B when the alarm was sounding because she didn't know how to contact the nurse. An interview with LPN-A on [DATE], at 9:17 a.m. established R1 was able to consistently use his call light and would request assistance from staff when he was anxious and/or short of breath. In addition, R1 was able to use his right hand and occasionally had accidentally disconnected the ventilator tubing by laying the right arm over the tubing. Due to R1's muscle weakness and ability to minimally use his right hand and arm only, staff were required to re-connect R1's ventilator tubing when it became disconnected. Staff were to position the tubing down the center of R1's chest to prevent accidental disconnection of the tubing. During that interview, LPN-A said prior to leaving nursing unit B for a scheduled break at 2:41 a.m. on [DATE], LPN-A said she informed nursing assistant (NA)-C and RN-B of her break. Prior to leaving the unit LPN-A said she checked on R1 who gave a thumbs up sign (indicated R1 was fine) when asked how he was doing. LPN-A said she punched back in from break (time clock) at 3:01 a.m. and used the bathroom prior to returning to the unit. When returning from break at approximately 3:05 a.m. and as LPN-A came closer to nursing unit desk B (110 feet from R1's room), she heard a ventilator alarm sounding. LPN-A passed two resident rooms that required ventilator support on her way to nursing unit desk B and those alarms were not sounding. LPN-A said NA-C was standing at the nursing unit desk B adjacent from R1's room and the alarm. LPN-A asked NA-C who's alarm was sounding. NA-C told LPN-A that R4's ventilator alarm was sounding but that NA-C had just checked on R4 and that resident was sleeping. LPN-A checked on R4 who's ventilator alarm was not sounding and next checked on R1 who's alarm was sounding. Upon entering R1's room at 3:05 a.m., LPN-A discovered the ventilator tubing was disconnected below the nebulizer adaptor approximately 6 inches from the [MEDICAL CONDITION] site. LPN-A said the low pressure alarm for the ventilator that was mounted on the wall outside R1's room was sounding and the ventilator inside the room was sounding. LPN-A reconnected the tubing which was lying underneath R1's right arm. LPN-A said R1's call light was not on. LPN-A removed the towel from R1's face. R1's skin was gray/white in color and R1's right arm from the elbow to his hand was mottled. R1's pupils were dilated and fixed and he had no radial pulse. LPN-A said she left R1's room and found RN-C within a few minutes who went in to assess R1. LPN-A said RN-C came out of R1's room within minutes and confirmed R1's death. LPN-A said RN-C left the area to assist another resident and LPN-A contacted the DON, physician, R1's family, and funeral home about R1's death. Interview with RN-B on [DATE], at 2:45 p.m. established LPN-A informed RN-B (unable to offer specific time) that she was leaving the unit for her break. RN-B said she was assisting residents at the opposite end of the facility during LPN-A's break. RN-B said when at the opposite end of the facility, she is unable to hear ventilator alarms. RN-B said staff were to contact RN-B during the night by calling the telephone at nursing unit desk A. RN-B said she did not hear the telephone ring during the time R1's ventilator alarm was sounding. RN-B said she was in the hallway walking toward nursing unit desk B when she heard LPN-A request her assistance with R1. RN-B went into R1's room and assessed R1. R1's gaze was fixed she did not check R1's pupils, skin color was pale gray, and R1's radial pulse was absent. RN-B left R1's room and informed LPN-A of the assessment and confirmed R1's death. RN-B left the area because another resident had passed away around the same time as R1. An interview with the respiratory therapist on [DATE], at 1:09 p.m. established he has a contract with the facility to service the residents' ventilators and check the alarms and ventilator settings for R1's equipment. The respiratory therapist stated the ventilator settings and alarms within the correct limits and functioning appropriately. Interview with the assistant director of nursing (ADON) on [DATE], at 10:54 a.m. established the alarm mounted outside the door leading into R1's room had sounded the low pressure alarm when the tubing was disconnected at 2:54 a.m. on [DATE]. The facility had determined LPN-A had discovered R1 at 3:00 a.m.(the resident was disconnected from the ventilator for 6 minutes). Interview with LPN-A on [DATE], at 9:17 a.m. established R1 was discovered at 3:05 a.m. (the resident was disconnected from ventilator for 11 minutes). Review of R1's certificate of death not dated, established the primary cause of death was asphyxiation (inability of an individual to acquire sufficient oxygen through breathing for an extended period of time) for an unknown amount of time. Interview with the DON on [DATE], at 9:36 a.m. established the facility expected all staff to respond to ventilator alarms. The DON revealed NA's had not been formally trained by the facility however, the NA's who orient the newly hired NA's were expected to instruct the new NA's to reconnect the ventilator tubing and find a licensed nurse for additional assistance. The DON said NA-C should have responded to R1's ventilator alarm, reconnected the ventilator tubing, and contacted the licensed nurse. The DON confirmed there was no formal system to contact a licensed nurse at the opposite end of the facility. The DON said a mandatory staff meeting for all licensed nurses and NAs was held on [DATE], and provided the contents of the meeting. Review of NA-C personnel file revealed NA-C had been hired 6 months prior to the incident. Review of the mandatory meeting minutes held on [DATE], revealed all staff were educated to respond to call lights, fall alarms and ventilator alarms. NAs were instructed to contact the licensed nurse after responding to a ventilator alarm and checking on the resident. The meeting minutes stated often repositioning may stop the ventilator alarm from sounding (did not identify what to reposition). The education did not include a method to ensure licensed nurse supervision of the residents that were ventilator dependent or a consistent and reliable means for the NAs to contact the licensed nurse. Review of the facility's Certified Nursing Assistant/Direct Care LPN-Night, Position Description, not dated, stated the NAs were to answer call lights and bed alarms but did not address responding to ventilator alarms. Review of the facility's policy and procedure titled Mechanical Ventilation Management with an approval date of [DATE], stated, "...All care to the ventilator-supported resident will be preformed under the supervision of the assigned nurse. Assigned nurse must be trained in ventilator care...and respond quickly to emergencies including...Accidental ventilator disconnection..." Review of the facility's policy and procedure titled Abuse Prevention/Resident Treatment with a revision date of [DATE], defined neglect as a failure to provide goods and services to a resident in order to prevent physical harm.

Based on document review and interview the facility failed to provide the necessary care and services to one of four ventilator dependent residents (R1) when staff failed to respond to R1's ventilator alarm which was sounding for at least six minutes. R1 was found deceased with the ventilator tubing disconnected. Findings include: Review of the facility's investigative report dated [DATE], revealed on [DATE], at approximately 3:05 a.m. licensed practical nurse (LPN)-A had returned to the nursing unit B following her break off the unit. At that time, LPN-A heard a ventilator alarm sounding. Nursing assistant (NA)-C was at the nursing unit desk B and indicated to LPN-A that R4's ventilator alarm was sounding. LPN-A checked and R1 not R4's ventilator alarm was sounding. At 3:05 a.m. upon entering R1's room, LPN-A observed the tubing leading from the ventilator to R1 [MEDICAL CONDITION] was disconnected with R1's right arm laying over the tubing. R1 had no pulse and pupillary (pupils) responses. At 3:05 a.m. R1 was pronounced dead. Review of R1's medical record revealed R1's [DIAGNOSES REDACTED]. to breath without ventilator support. Because of that diagnosis, R1 was ventilator dependent for breathing since [DATE]. R1 also had a history of [REDACTED]. Upon R1's admission to the facility, R1 choose not to be resuscitated if R1 had a respiratory or [MEDICAL CONDITION] (not breathing and no pulse). Review of R1's plan of care in place at the time of the [DATE] incident, revealed R1 was unable to speak due to the [MEDICAL CONDITION] (an opening through the resident's neck into the trachea where a tube was placed to provide an airway to the lungs) and ventilator. Staff were to anticipate R1's needs, encourage a communication board, and non-verbal communication. Staff were to ask questions that had a yes/no response and occasionally R1 could point at objects or mouth words. The care plan established R1 was dependent on the ventilator, was alert and oriented. An area added to the care plan and not dated, stated, R1 had an alteration in cognition related to tactile and visual hallucinations (R1 frequently would see and feel bugs mostly at night). To lessen the hallucinations, R1 preferred to sleep with a towel over his head at night. R1 was dependent on staff for turning and repositioning and required assistance from two staff and a mechanical sling lift for transfers and staff assistance with incontinence care every two hours. R1 took nothing by mouth and was fed with tube feedings. Care planned interventions for the ventilator and [MEDICAL CONDITION] care included suctioning the [MEDICAL CONDITION] as needed (usually 1 time a shift), ventilator checks every 3 hours and as needed, changing the ventilator tubing weekly, oxygen saturation levels every shift, licensed staff to check the [MEDICAL CONDITION] cuff for proper inflation every shift, and a RN to change the [MEDICAL CONDITION] every month. R1's physician orders [REDACTED]. The oxygen was to be kept at 0 to 5 liters to keep the oxygen saturation level > 92 %. The orders indicated R1 received [MEDICATION NAME] (anti-anxiety medication) 1 mg (milligrams) in the morning and 0.75 mg mid-day and at bedtime with 0.5 mg every 2 hours as needed for anxiety. Review of the facility's Ventilator Check Sheet form for R1 dated [DATE] through [DATE], completed by licensed staff every 3 hours, revealed R1's respiratory rate was normally with the respirator setting at 12 breath per minute and approximately three to five times a day was 13 to 17 breaths per minute (3 to 5 breaths above the respirator setting). The Medication Administration Record [REDACTED]. Review of the facility's Daily Behavior Observation Tool from [DATE] to 24, 2013, revealed R1's target behaviors identified by the facility included: anxiety with shortness of breath related to ventilator use, fearfulness of not getting air, and hallucinations. The tool established R1 had 1 to 3 episodes a day of shortness of breath related to the ventilator use. The interventions documented included calm reassurance, redirection, and [MEDICATION NAME]. R1's MAR from [DATE] until [DATE], revealed in addition to the scheduled [MEDICATION NAME], R1 had requested as needed [MEDICATION NAME] from one to three times a day for complaints of shortness of breath. R1's shortness of breath was relieved with the [MEDICATION NAME]. The nurse practitioner progress note dated [DATE], indicated R1 was started on Z-Pak (antibiotic) 500 mg one time and 250 mg four additional days on [DATE], for increased lung congestion and thick white/yellow secretions suctioned from the [MEDICAL CONDITION]. A sputum culture was obtained which was positive for pseudomonas (bacteria) and the antibiotic was changed to [MEDICATION NAME] (sensitive to pseudomonas) 500 mg every day for 7 days. The last dose of [MEDICATION NAME] was administered to R1 on [DATE]. R1 refused hospitalization and preferred to be medically managed at the facility. Staff were to notify the physician with any acute (sudden) changes in R1's respiratory status and/or a temperature above 99.6 degrees Fahrenheit. The note established R1 had a history of [REDACTED]. The note indicated R1's respiratory status had continued to improve with the antibiotic. A nursing progress note dated [DATE], at 12:30 a.m. revealed R1 had received a scheduled nebulizer treatment and was suctioned for thick green/yellow sputum with continued complaints of shortness of breath. R1 was given [MEDICATION NAME] 0.5 mg and suctioned again for a large amount of clear/green sputum with relief of R1's anxiety and shortness of breath. The nursing progress note dated [DATE], at 2:30 a.m. indicated staff had checked R1 who was awake and indicated to staff that his breathing was improved. R1's oxygen saturation was 98 % at 4 liters of oxygen. The nursing progress note dated [DATE], at 3:05 a.m. revealed LPN-A heard R1's ventilator alarm sounding and checked on R1. R1's ventilator tubing was under R1's right arm and disconnected. R1 had no pulse, the right anticubital area (elbow) was mottled, facial color was ashen/gray, and the pupils were dilated and fixed. RN-B completed an assessment and pronounced the resident's death. At 3:20 a.m. the DON, family, physician, and funeral home were contacted of R1's death. On [DATE], observations were made of the facility. The facility's floor plan was square shaped with a tail at one end of the square (similar to a P shape) that created on long hallway. Nursing unit desk A was located at the top corner of the square and at the beginning of the tail that created a long hallway. The nursing unit desk B was at the lower portion of the square (same side of nursing unit desk A) located at the middle of a long hallway (that was created by the tail). The rooms of the 4 residents that required ventilator support were located at the lower portion of the square and at the middle portion of the long hallway, all near nursing unit desk B. On [DATE], at 10:30 a.m. the distance was measured with the maintenance director from the nursing unit desk B to R1's room which was 30 feet. Interview with the DON on [DATE], at 9:36 a.m. established the night shift (10:00 p.m. until 6:30 a.m.) was staffed with two licensed nurses, one assigned to nursing unit A and one assigned to nursing unit B. In addition, two to three NAs were scheduled on the night shift. Usually there was one NA on nursing unit A and one NA on nursing unit B. On [DATE], the night of the incident, there were two licensed staff and two NA's working the night shift. Interview with NA-C on [DATE], at 9:45 a.m. established on [DATE], NA-C had been completing rounds (checking on residents) in resident rooms when LPN-A left nursing unit B for her break (unable to indicate time). NA-C said she started rounds at approximately 2:30 a.m. and R1 was the fourth resident she had assisted with cares. NA-C said she had assisted R1 with incontinence care and repositioning and R1 was awake during cares. Prior to leaving R1's room, NA-C said R1 was repositioned on his/her back and she placed the call light in R1's hand, clipped the light to R1's gown, placed the towel over R1's face as requested by R1, and placed the ventilator tubing down the center of R1's chest. NA-C said she finished rounds and sometime before 3:00 a.m. returned to nursing unit B desk, NA-C said she heard a ventilator alarm sounding in the hallway when she returned to the nursing unit desk B. NA-C checked on R4 (room across the hall from R1) who was asleep and went back to the nursing unit desk B. NA-C did not check R1. NA-C said she heard the alarm sound for approximately 5 minutes. NA-C said she had not been trained by the facility to reconnect ventilator tubing or to respond to ventilator alarms. NA-C said the licensed nurses always responded to the ventilator alarms. NA-C did not attempt to contact RN-B when the alarm was sounding because she didn't know how to contact the nurse. An interview with LPN-A on [DATE], at 9:17 a.m. established R1 was able to consistently use his call light and would request assistance from staff when he was anxious and/or short of breath. In addition, R1 was able to use his right hand and occasionally had accidentally disconnected the ventilator tubing by laying the right arm over the tubing. Due to R1's muscle weakness and ability to minimally use his right hand and arm only, staff were required to re-connect R1's ventilator tubing when it became disconnected. Staff were to position the tubing down the center of R1's chest to prevent accidental disconnection of the tubing. During that interview, LPN-A said prior to leaving nursing unit B for a scheduled break at 2:41 a.m. on [DATE], LPN-A said she informed nursing assistant (NA)-C and RN-B of her break. Prior to leaving the unit LPN-A said she checked on R1 who gave a thumbs up sign (indicated R1 was fine) when asked how he was doing. LPN-A said she punched back in from break (time clock) at 3:01 a.m. and used the bathroom prior to returning to the unit. When returning from break at approximately 3:05 a.m. and as LPN-A came closer to nursing unit desk B (110 feet from R1's room), she heard a ventilator alarm sounding. LPN-A passed two resident rooms that required ventilator support on her way to nursing unit desk B and those alarms were not sounding. LPN-A said NA-C was standing at the nursing unit desk B adjacent from R1's room and the alarm. LPN-A asked NA-C who's alarm was sounding. NA-C told LPN-A that R4's ventilator alarm was sounding but that NA-C had just checked on R4 and that resident was sleeping. LPN-A checked on R4 who's ventilator alarm was not sounding and next checked on R1 who's alarm was sounding. Upon entering R1's room at 3:05 a.m., LPN-A discovered the ventilator tubing was disconnected below the nebulizer adaptor approximately 6 inches from the [MEDICAL CONDITION] site. LPN-A said the low pressure alarm for the ventilator that was mounted on the wall outside R1's room was sounding and the ventilator inside the room was sounding. LPN-A reconnected the tubing which was lying underneath R1's right arm. LPN-A said R1's call light was not on. LPN-A removed the towel from R1's face. R1's skin was gray/white in color and R1's right arm from the elbow to his hand was mottled. R1's pupils were dilated and fixed and he had no radial pulse. LPN-A said she left R1's room and found RN-C within a few minutes who went in to assess R1. LPN-A said RN-C came out of R1's room within minutes and confirmed R1's death. LPN-A said RN-C left the area to assist another resident and LPN-A contacted the DON, physician, R1's family, and funeral home about R1's death. Interview with RN-B on [DATE], at 2:45 p.m. established LPN-A informed RN-B (unable to offer specific time) that she was leaving the unit for her break. RN-B said she was assisting residents at the opposite end of the facility during LPN-A's break. RN-B said when at the opposite end of the facility, she is unable to hear ventilator alarms. RN-B said staff were to contact RN-B during the night by calling the telephone at nursing unit desk A. RN-B said she did not hear the telephone ring during the time R1's ventilator alarm was sounding. RN-B said she was in the hallway walking toward nursing unit desk B when she heard LPN-A request her assistance with R1. RN-B went into R1's room and assessed R1. R1's gaze was fixed she did not check R1's pupils, skin color was pale gray, and R1's radial pulse was absent. RN-B left R1's room and informed LPN-A of the assessment and confirmed R1's death. RN-B left the area because another resident had passed away around the same time as R1. An interview with the respiratory therapist on [DATE], at 1:09 p.m. established he has a contract with the facility to service the residents' ventilators and check the alarms and ventilator settings for R1's equipment. The respiratory therapist stated the ventilator settings and alarms within the correct limits and functioning appropriately. Interview with the assistant director of nursing (ADON) on [DATE], at 10:54 a.m. established the alarm mounted outside the door leading into R1's room had sounded the low pressure alarm when the tubing was disconnected at 2:54 a.m. on [DATE]. The facility had determined LPN-A had discovered R1 at 3:00 a.m.(the resident was disconnected from the ventilator for 6 minutes). Interview with LPN-A on [DATE], at 9:17 a.m. established R1 was discovered at 3:05 a.m. (the resident was disconnected from ventilator for 11 minutes). Review of R1's certificate of death not dated, established the primary cause of death was asphyxiation (inability of an individual to acquire sufficient oxygen through breathing for an extended period of time) for an unknown amount of time. Interview with the DON on [DATE], at 9:36 a.m. established the facility expected all staff to respond to ventilator alarms. The DON revealed NA's had not been formally trained by the facility however, the NA's who orient the newly hired NA's were expected to instruct the new NA's to reconnect the ventilator tubing and find a licensed nurse for additional assistance. The DON said NA-C should have responded to R1's ventilator alarm, reconnected the ventilator tubing, and contacted the licensed nurse. The DON confirmed there was no formal system to contact a licensed nurse at the opposite end of the facility. The DON said a mandatory staff meeting for all licensed nurses and NAs was held on [DATE], and provided the contents of the meeting. Review of NA-C personnel file revealed NA-C had been hired 6 months prior to the incident. Review of the mandatory meeting minutes held on [DATE], revealed all staff were educated to respond to call lights, fall alarms and ventilator alarms. NAs were instructed to contact the licensed nurse after responding to a ventilator alarm and checking on the resident. The meeting minutes stated often repositioning may stop the ventilator alarm from sounding (did not identify what to reposition). The education did not include a method to ensure licensed nurse supervision of the residents that were ventilator dependent or a consistent and reliable means for the NAs to contact the licensed nurse. Review of the facility's Certified Nursing Assistant/Direct Care LPN-Night, Position Description, not dated, stated the NAs were to answer call lights and bed alarms but did not address responding to ventilator alarms. Review of the facility's policy and procedure titled Mechanical Ventilation Management with an approval date of [DATE], stated, "...All care to the ventilator-supported resident will be preformed under the supervision of the assigned nurse. Assigned nurse must be trained in ventilator care...and respond quickly to emergencies including...Accidental ventilator disconnection..." Review of the facility's policy and procedure titled Abuse Prevention/Resident Treatment with a revision date of [DATE], defined neglect as a failure to provide goods and services to a resident in order to prevent physical harm.