Every finding on record at Friendship Village Retirement

Based on observation, clinical record review, interviews, and policy review the facility failed to monitor and maintain documentation of a resident's bruises for 1 of 1 residents reviewed (Resident #1). Additionally, the facility failed to obtain x-ray results for a resident with hip pain after falling for 11 days for 1 of 1 residents reviewed (Resident #3). The facility reported a census of 60 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) dated [DATE] listed diagnoses of weakness, edema (fluid swelling), and a history of falls. Resident #1's Brief Interview for Mental Status (BIMS) assessment showed a score of 13, indicating intact cognition. The assessment noted no skin concerns. Resident #1's Care Plan (CP) created 4/22/26 directed nursing staff and Certified Nurses' Aides (CNAs) to conduct weekly skin inspections for redness, open areas, scratches, cuts, and bruises and to report changes to the nurse. On 7/6/26 at 11:03 AM Resident #1 stated falls occurred due to a prior stroke. Resident #1 reported bruises from the last fall on the head, face, and arm healed. Resident #1 couldn't provide the date of the fall. A Progress Note dated 5/3/26 at 10:31 PM documented Resident #1 fell from the edge of the bed and hit the head hard on the floor. A Progress Note dated 5/4/26 at 1:27 AM indicated Resident #1 had visible swelling on the right side of the head. The left pupil measured larger and non-reactive. After consultation with family and the provider, the facility sent Resident #1 to the emergency room (ER). On 7/8/26 at 10:33 AM Staff B, Registered Nurse (RN), stated the floor nurse usually documented bruising monitoring at least weekly on shower days in the assessment tab of the Electronic Health Record (EHR). Staff B stated the facility employed a skin nurse, but the nurse's focus remained mostly on wound treatment and pressure sores. A document titled Skin Check dated 5/6/26 at 3:15 PM, section 1.8, documented no skin issues. A Progress Note dated 5/13/26 at 8:49 PM titled Skin Check indicated no skin issues or new skin issues. A Progress Note dated 5/13/26 at 8:51 PM documented facial bruising from a previous fall showed various degrees of healing. The facility didn't provide documentation of the initial bruising assessment, location of bruises, size of bruises, or monitoring of bruising or swelling on Resident #1's head. On 7/8/26 at 3:55 PM the Director of Nursing (DON) stated the skin nurse tracked pressure sores and staff held a weekly skin meeting. The DON reported the EHR felt new to the facility and staff still navigated the documentation. The DON expected the documentation to reside in the skin module and acknowledged she didn't see the documentation for Resident #1. 2. Resident #3's Minimum Data Set (MDS) dated [DATE] documented diagnoses of osteoporosis (bone thinning), Alzheimer's disease (brain disorder), and a history of falls. Resident #3 received a BIMS score of 99, indicating an incomplete interview, and the staff assessment indicated cognition showed severe impairment with both long-term and short-term memory problems. Resident #3's EHR revealed Resident #3 fell on 6/20/26, 6/22/26, and 6/23/26. A Progress Note dated 6/24/26 at 6:00 PM indicated the facility received a fax from the provider's office about the 6/23/26 incident, yielding a new order for a right hip x-ray. The facility sent a return fax to the provider requesting clarification for the number of x-rays and asking if the order could include a portable x-ray. A Progress Note dated 6/26/26 at 11:35 AM reported the facility received a response from the provider for a STAT (immediately) portable x-ray of the right hip, 3 views, with diagnoses of pain, decreased mobility, and dementia (memory loss). A review of Resident #3's paper records and EHR on 7/6/26 showed no progress note documenting x-ray completion or results as of 1:05 PM. A document titled Patient Report dated 6/26/26 at 2:03 PM indicated Resident #3's x-ray revealed no acute fracture and mild degenerative changes. The document header showed the fax arrived at the facility on 7/7/26. On 7/8/26 at 3:36 PM Staff G, X-Ray Provider Representative, stated the company originally faxed the results to the facility at a number provided on 6/26/26. Staff G noted on 7/7/26 at 9:06 AM the facility called for a refax and provided a different number. Staff G reported no indication the facility called between 6/26/26 and 7/7/26 to request the results. Staff G stated they don't fax the results to the doctor's office because providers and patients move too much and sending them to the nursing home yields better results. On 7/8/26 at 3:47 PM Staff F, Provider's Clinic Nurse, confirmed they didn't receive the x-ray results until the facility faxed them on 7/7/26. Staff F responded to the facility on 7/8/26 at 9:49 AM. On 7/8/26 at 3:55 PM the DON stated the turnaround time for x-ray results depended on the x-ray provider. When asked about follow-up responsibility, the DON stated she thought the company faxed Resident #3's results to the primary care provider. The DON stated the facility faxed them yesterday. The DON confirmed staff didn't contact the x-ray provider or the primary care provider until 7/7/26. The Fall Reduction Policy and Procedure revised April 2023 directed staff to investigate and document fall circumstances, resident outcome, and staff response. The policy instructed the nurse to notify the primary care provider and implement an immediate intervention.

Based on observation, clinical record review, facility records, interviews, and policy review, the facility failed to provide adequate supervision for 2 of 3 residents reviewed for falls (Resident #1 and Resident #3). Resident #1 fell after a Certified Nurses' Aide (CNA) transferred them to the edge of the bed and then moved a wheelchair to the bathroom. Additionally, Resident #3 required assistance from a CNA, but the staff left them alone in the bathroom while the CNA assisted another resident. In addition, the facility failed to use foot pedals while pushing Resident #3 who needed assistance in their wheelchair. The facility reported a census of 60 residents.Findings include:1. Resident #1's Minimum Data Set (MDS) dated [DATE] recorded diagnoses of a Cerebrovascular Accident (CVA, stroke), a history of falling, and weakness. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 13, indicating intact cognition. Section GG of the MDS recorded Resident #1 required substantial to maximal assistance (helper does more than half of the work) to transfer to and from a chair and a bed, and to move from sitting on the side of the bed to lying flat on the bed. Therapy Recommendations dated 12/1/25 directed staff to use a Standing Pivot Transfer (SPT) with a four-wheeled walker, right platform, and the assistance of two staff members for Resident #1. Resident #1's Care Plan (CP) included an intervention created 4/22/26 directing two staff members to transfer Resident #1 into or out of bed. An intervention updated 5/3/26 indicated Resident #1 had a fall, modifying the transfer instruction to an assistance of two staff members for all SPT with a platform walker and gait belt (transfer safety belt). On 7/6/26 at 10:48 AM Resident #1 sat in a wheelchair in the room wearing a leg brace on the right leg. Two staff members entered the room to provide continence care (toileting assistance), which included using a gait belt. On 7/6/26 at 11:03 AM Resident #1 stated sometimes one person and sometimes two people helped Resident #1 to bed, though Resident #1 believed staff always utilized two people since the last fall. Resident #1 reported the bruises on the head, face, and arm from the fall healed. Resident #1 couldn't provide the exact date of the fall. An Incident Statement dated 5/3/26 reported by Staff A, Certified Nurses Aide (CNA), to Staff B, Registered Nurse (RN), documented Staff A transferred Resident #1 to the incontinence pad (disposable bed pad) on the bed. Resident #1 sat upright, holding the bed side rail. Staff A placed the wheelchair inside the bathroom when Resident #1 leaned over and fell onto the floor, hitting the head. A Progress Note dated 5/4/26 at 12:49 AM documented Resident #1 returned to the facility from the hospital. Diagnoses included a fall and a contusion (bruise) of the right shoulder. Imaging of the cervical spine (neck bones) and head showed negative results. A CNA assisted Resident #1 to the bathroom and to bed. A Progress Note dated 5/4/26 at 1:27 AM documented discomfort on the right side of Resident #1's head with visible swelling, along with discomfort in the left hip and right shoulder. The note indicated Resident #1 maintained the ability to transfer with the assistance of one staff member and a gait belt. On 7/8/26 at 10:33 AM Staff B stated following the fall of Resident #1, staff assessed for pain, range of motion (joint movement), vital signs, and completed a neurological assessment (brain and nerve evaluation). Resident #1's pupils didn't show equal size, and Resident #1 received medication for blood clotting, so staff consulted the family and the doctor before sending Resident #1 to the hospital. Staff B indicated Staff A reported performing some of Resident #1's cares, sitting Resident #1 on the edge of the bed, and moving the wheelchair into the bathroom. As Staff A walked back, Resident #1 slid off the bed. Staff B confirmed only one CNA accompanied Resident #1 and believed the care plan allowed this setup. On 7/8/26 at 11:51 AM Staff C stated she wouldn't leave a resident on the side of the bed. She reported two staff members should stand on each side of the resident, hold the gait belt, and help pivot the resident from the wheelchair to the bed. The staff should then scoot the resident back onto the bed and swing the legs into place. Staff C felt the procedure offered greater safety for any resident. She stated Resident #1 normally required assistance of one staff member, but staff utilized two because Resident #1's right side remained weak. On 7/8/26 at 3:55 PM the Director of Nursing (DON) stated Staff A placed Resident #1 at the edge of the bed and moved the wheelchair out of the way into the bathroom. The DON expressed no problem with this action because Staff A didn't leave the room. She said Resident #1 simply fell forward. The DON confirmed only one CNA assisted Resident #1 because staff finished toileting, lotion, and hair care. When questioned if she expected the CNA to finish all cares and place Resident #1's feet up before moving the chair, she stated following the fall, the facility added therapy for trunk control (torso stability), and Resident #1's care plan now required getting Resident #1 fully into bed for safety. When asked if staff completed additional fall training after this incident, she stated staff mentioned it during one huddle (brief staff meeting). A document titled Nursing Meeting dated 5/12/26 - 5/13/26 didn't include Resident #1's incident. The daily huddle topic noted to make sure staff check fall interventions remain in place each time staff leave a resident alone in a room. The facility didn't maintain signatures to confirm the specific staff members who participated in the meeting or huddles. 2. Resident #3's Minimum Data Set (MDS) dated [DATE] documented diagnoses of osteoporosis (bone thinning), Alzheimer's disease (progressive brain disorder), and a history of falling. Resident #3 couldn't complete the BIMS assessment, resulting in a score of 99, indicating an incomplete interview. The staff assessment indicated severe cognitive impairment with both long-term and short-term memory problems. The MDS indicated Resident #3 required partial to moderate assistance (helper does less than half of the work) for toileting hygiene and depended entirely on staff for toilet transfers. Resident #3's Care Plan dated 3/26/26 included a focus area for Activities of Daily Living (ADL) self-care deficits related to impaired balance, dementia, and Parkinson's disease (nervous system disorder). Interventions included the assistance of one staff member for toileting and transfers, and notes designated Resident #3 at high risk for falls, requiring frequent checks and assistance to use the bathroom. An additional intervention dated 3/12/26 documented Resident #3 utilized a wheelchair for mobility. The plan directed staff to encourage Resident #3 to allow staff to move foot pedals out of the way during transfers because Resident #3 would pull them back and step over them. On 7/6/26 at 11:41 AM Staff E pushed Resident #3's wheelchair from a rust-colored chair in the common area to the dining room without foot pedals, covering a distance of approximately 50 feet. On 7/7/26 at 11:40 AM Resident #3 Representative stated awareness concerning Resident #3's numerous falls. Resident #3 Representative felt the falls related closely to memory loss, Parkinson's disease, and Resident #3 living out of habit without understanding the inability to perform tasks independently. Resident #3 Representative believed a staff member remained in the bathroom with Resident #3 whenever possible. A Progress Note titled Incident Note dated 6/20/26 at 11:15 AM documented a CNA assisted Resident #3 to the toilet. The CNA left the room to help another resident and advised an alternate CNA regarding Resident #3's presence in the bathroom. A housekeeper entered the room and discovered Resident #3 on the bathroom floor. The note included an immediate intervention directing staff to avoid leaving Resident #3 unattended while toileting. The facility didn't provide an associated incident report or alternative fall investigation documentation related to the 6/20/26 fall. On 7/8/26 at 10:23 AM Staff D stated she wouldn't leave a resident alone upon knowing the resident couldn't use the bathroom call light. She stated staff shouldn't leave Resident #3 alone in the bathroom, though Resident #3 refused to use the toilet if staff remained inside. Staff D noted CNAs often partially closed the door and stayed close to it, confirming she wouldn't leave the room. On 7/8/26 at 11:51 AM Staff C stated staff couldn't leave Resident #3 alone. She noted staff might step out of the bathroom but must stay in the room. She stated staff should never push a wheelchair without foot pedals. On 7/8/26 at 12:21 PM Staff E stated Resident #3 could use his feet to move the wheelchair and frequently moved foot pedals back into place after staff adjusted them to the side. When asked if pushing the wheelchair without pedals constituted normal practice, she stated she might perform the action under certain circumstances but usually avoided it. She acknowledged completing this action before. On 7/8/26 at 3:55 PM the DON stated she believed Resident #3 remained on the bathroom floor for 15 minutes or less from the time the CNA left the bathroom until the housekeeper discovered him. She said her investigation of the call lights revealed multiple alarms activated at that time, so she didn't believe the CNA notified of Resident #3's status managed to check on him. She stated she suggested staff stand outside the door when Resident #3 rejected their presence in the bathroom, though she acknowledged staff didn't always follow this practice. When asked if staff should leave Resident #3 alone, she answered no, based on the care plan. The DON stated she expected foot pedals on a wheelchair if staff pushed a resident. She reported no awareness of additional fall training for staff after this incident. The Fall Reduction Policy and Procedure revised April 2023 directed staff to investigate and document fall circumstances, resident outcomes, and staff responses. The policy instructed staff to provide education on fall prevention at mandatory CNA and nurse meetings.

Based on Electronic Health Record (EHR) review, the Centers for Medicare and Medicaid Services (CMS) Long term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interviews the facility failed to accurately code 1 of 1 resident (Resident #9) Minimum Data Set (MDS) assessment for hospice services during the look back period. The facility reported a census of 66.Findings include:Resident #9's MDS assessment dated [DATE] lacked documentation for hospice care. The MDS documented diagnoses of coronary artery disease (poor blood flow from the heart), hypertension (high blood pressure), peripheral vascular disease (poor blood flow in the blood vessels returning to the heart), hyperlipidemia (high bad cholesterol) and depression. The MDS Coordinator electronically signed the MDS on 9/10/25 verifying assessment completion. In an interview on 9/24/25 at 4:02 PM, the MDS Coordinator acknowledged she is responsible for completing the MDS assessments. The MDS Coordinator identified Resident #9 received hospice care. The MDS Coordinator stated the MDS assessment dated [DATE] missed coding hospice care for Resident #9. The MDS Coordinator acknowledged she followed the RAI manual for coding MDS assessments.In an interview on 9/24/25 at 4:10 PM, the Director of Nursing (DON) acknowledged the MDS assessment dated [DATE] lacked documentation for hospice care. The DON verbalized she expected the MDS assessments completed accurately.The Centers for Medicare and Medicaid Services (CMS) Long term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 instructed to code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions.

Based on clinical record review, document review and staff interview, the facility failed to complete a new level 1 Preadmission Screening and Resident Review (PASRR) screening for 1 of 1 resident's sampled (Resident #19). The facility identified a census of 66 residents. Findings include: Resident #19's Electronic Admission Record listed an admitted [DATE]. Resident #19's PASRR screening dated 8/28/23 documented the following: a. Diagnoses - no mental health diagnoses is known or suspected and no dementia/neurocognitive disorders. b. Behaviors and Symptoms - no known mental health behaviors which affected interpersonal interactions; no known mental health symptoms affecting the individual's ability to think through or complete tasks which she/he should be physically capable of completing; no known recent or current mental health symptoms. c. Services and Other Indicators - no, individual has not received mental health services now or in the past. d. Mental Health Medications - no medications listed. The PASRR documented no level two required as of 8/28/23. The Care Plan Category dated 9/14/23 reflected Resident #19 had a Behavioral Problem. The Care Plan indicated Resident #19 had a risk for behavioral disturbance related to signs and symptoms of anxiety, calling out for help, needing additional staff presence, support, and delusions. At times may display aggressive behavior toward others. A family member reported attention seeking behaviors. The Care Plan directed the following: a. 9/14/23: Staff to provide orientation to Resident #19 during times of confusion, anxiety, and delusional thinking b. 9/14/23: Attempt reality orientation during times of delusions. c. 10/16/23: Aggressive behavior toward another resident. Staff provide one to one supervision as needed. The Care Plan Category dated 9/29/23 identified Resident #19 received high risk antipsychotic medication related to behaviors with delusions. The Care Plan directed the following dated 9/29/23: a. Administer the medication per the physician order b. Monitor for medication side effects. c. Perform an abnormal involuntary movement scale (AIMS, a test to monitor for side effects of long-term use of antipsychotic medications) assessment every 3-6 months; d. Monitor for desired effect of the medication e. Provide gradual dose reductions per the pharmacy recommendations. The Care Plan Category dated 10/11/23 outlined Resident #19 received high risk antianxiety medications. The Intervention directed to monitor the use of the medication. Resident #19's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS indicated Resident #19 had other behaviors not directed toward others (examples physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing, throwing food or bodily waste, or verbal/vocal symptoms like screaming, disruptive sounds) occurring 1-3 days per week. The MDS included a diagnosis of hypertension (high blood pressure). Resident #19 used antipsychotic, antianxiety and antidepressant medications during the lookback period. Resident #19's MDS assessment dated [DATE] identified a BIMS score of 5, indicating a severely cognitively impaired. The MDS lacked documentation of signs of delirium or behaviors. The MDS included diagnoses of hypertension and psychotic disorder. The MDS indicated Resident #19 received antipsychotic medication during the lookback period. The Quarterly MDS assessment dated [DATE] showed a BIMS score of 10 indicating a moderate cognitive loss. The MDS indicated Resident #19 did not exhibit signs of delirium, mood or behavioral symptoms. The MDS included diagnoses of stroke, hypertension, and psychotic disorder. Resident #19 used antipsychotic medication during the lookback period. A 4/3/24 Neuropsychiatry Progress Note documented Resident #19's visit due to a chief complaint of a primary diagnosis of mood disorder, anxiety, and psychosis in the elderly. Resident #19 had a behavior disturbance and used a medication order for Risperidone 1 MG tablet by mouth twice a day and Trazodone 25 milligrams (MG) by mouth nightly. An 8/5/24 Nurse Practitioner Note documented Resident #19 had diagnoses of dementia and being a poor historian. Further clinical record review showed Resident #19 didn't receive their diagnosis of dementia until the 8/5/24 visit. A 10/7/24 review of Resident #19's clinical record revealed the following physician orders since admission: a. 9/15/23: Physician Order request for psychiatric consult due to increased confusion, hallucinations, and anxiety. b. 9/22/23: signed Physician Order for Haldol (antipsychotic medication) 2.5 MG by mouth one time only. c. Pharmacist Recommendation to Prescriber 9/22/23 for clinical rationale to continue as needed lorazepam (antianxiety) 0.5 MG written effectively treats anxiety. d. 10/6/23: signed Physician Order for Trazodone (antidepressant medication) 25 MG by mouth every hour of sleep (HS or bedtime). e. 10/11/23: Physician Order to increase Risperidone (antipsychotic medication, brand name Risperdal) 0.5 MG by mouth twice a day for a diagnosis of mood disorder. f. 10/25/23: signed Physician Order for Risperdal (antipsychotic medication) 1 MG by mouth twice a day. f. 10/25/23: Physician Order Sheet and Progress Note with documentation of new diagnosis for psychosis in the elderly with behavioral disturbance. A 10/9/24 Physician Visit Note documented the reason for visit as diagnoses of mood disorder (primary), anxiety, and psychosis in the elderly with behavioral disturbance. The Note listed a current physician order for Risperdal 1 MG by mouth two times a day. The Note included the diagnoses of anxiety and psychosis in the elderly with behavioral disturbance as a current diagnosis since 9/15/23 and the diagnosis of mood disorder current since 10/11/23. During an interview on 10/9/24 at 10:20 AM the Social Worker, reported she would re-screen the PASRR if the resident had an in-patient psychiatric hospital stay, which they didn't have any, or if the resident received a new psychiatric diagnosis. On 10/9/24 at 1:16 PM the Social Worker verbalized she updated the PASRR assessment that day and had a pending review at the time. She reviewed the 4/3/24 Psychiatric Visit note highlighting the chief complaint as seeing Resident #19 for mood disorder, anxiety, and psychosis in the elderly with behavioral disturbance. She verbalized agreement someone should have updated the PASRR in September/October 2023 when they started seeing Psychiatry. During an interview on 10/9/24 at 2:55 PM the Administrator and Director of Nursing both verbalized they expected the staff to follow the facility policy. In addition, they expected the staff to re-screen a resident to be re-screened for PASRR when a new psychiatric diagnosis is written. The PASRR Policy and Procedure, dated August 2023, directed if a resident experienced a new mental illness diagnosis, the PASRR will be updated.

Based on record review and staff interview the facility failed to accurately code 1 of 16 residents Minimum Data Set (MDS) accurately (Resident #59). The facility reported a census of 66 residents. Findings include: Record review of Resident #59 MDS dated [DATE] documented she had a fall with major injury (bone fractures, joint dislocation, closed head injury with altered consciousness, and subdural hematoma) while living at the facility. On 10/9/2024 at 11:36 AM the Administrator reported the facility coded Resident #59's fall with major injury in error and they would fix it. Record review of Resident #59's MDS dated [DATE] with an attestation date of 10/9/24 listed the reason for modification as an item coding error.

Based on clinical record review, observations, staff, resident, and family interviews the facility failed to provide adequate supervision for 1 of 3 residents reviewed with falls (Resident #1). On 1/25/24, Resident #1 fell while receiving assistance from a Certified Nurse Aide (CNA). As the CNA assisted Resident #1 she failed to apply a gait belt. The fall resulted in a hip fracture to Resident #1's right hip that required surgical repair. The facility reported a census of 63. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a staff assessment for mental status. The assessment reflected Resident #1 had an ok short-term memory and could make independent decisions. Resident #1 required partial to moderate assistance with walking 10 - 150 feet. She used a wheelchair for mobility. The MDS included diagnoses of stroke, hemiplegia (complete paralysis on one side of the body), major depressive disorder, edema, and reduced mobility. The Care Plan Problem dated 1/18/24 reflected Resident #1 had a potential for injury related to a stroke with right sided residual (long lasting) weakness and a history of falls. The Interventions directed the following: a. 8/12/23: Use proper footwear with any stand, pivot, transfer and a gait belt. b. 1/25/24: Informed the staff Resident #1 experienced a fall and went to the emergency room for evaluation with right hip pain. The new fall intervention indicated the staff received education that all residents who require assistance from 1 staff for transfers or ambulation must have on a gait belt. Review of an interdisciplinary note dated 1/25/24 reflected Resident #1 experienced a fall at approximately 9:05 PM. Staff A, Licensed Practical Nurse (LPN), reported being outside Resident #1's room when she heard a loud crash and a scream coming from there. Staff A entered the room and found Resident #1 on her right side in front of her chair. She screamed, My hip, my hip hurts. The nursed assessed her for injuries, and called the physician for an order to transfer her to a local hospital for evaluation. The note indicated the nurse asked Staff B what occurred. Staff B, Certified Nurse Aide (CNA) stated as they walked Resident #1 to bed with her walker, the walker caught on the tray table, causing her to trip, and fall. The local hospital's History and Physical dated 1/25/24 indicated Resident #1 arrived at the emergency room after she fell on her right side, resulting in excruciating right hip pain. The physician ordered x rays revealing a femoral neck fracture. The surgical consult team recommended admitted Resident #1 for surgical correction. The Assessment and Plan listed Resident #1 had a right hip fracture. The X-Ray Results dated 1/25/24 at 10:28 PM reflected Resident #1 had an impacted fracture of the right femoral neck. The Gait Belt Policy and Procedure dated May 2023 indicated the staff must use a gait belt at all times when transferring and/or walking residents that are not independent. All direct care workers receive a gait belt upon employment. They should place the gait belt around the resident's waistline when transferring or walking them. Ensure the gait belt is secure and but not creating discomfort. Staff need to grasp the sides of the gait belt during pivot transfers or grasp the back of the belt while ambulating the resident. Failure to use a gait belt may result in disciplinary action up to and including termination. The Investigation Summary of the Self-Report dated 1/26/24 identified Resident #1 had a fall with an injury, resulting in a transfer to a local emergency room . The conclusion of the investigation summary indicated the CNA assisting Resident #1 when she fell , failed to use a gait belt while transferring her. On 7/16/24 at 9:02 AM Staff A, Licensed Practical Nurse (LPN), reported she worked the evening shift on 1/25/24 when Resident #1 experienced a fall in her room. Staff A explained she responded to a crashing noise followed by screaming. Upon entering Resident #1's room she found her on the floor laying on her right side. Staff A assessed Resident #1 and sent her to a local emergency room . Staff A indicated when she entered Resident #1's room and saw her on the floor she didn't have a gait belt on. Staff A interviewed Staff B, CNA, who assisted Resident #1 in her room, Staff B stated she forgot to put a gait belt on Resident #1 prior to walking her. On 7/16/24 at 7:20 AM Staff D, Registered Nurse (RN)/Assistant Director of Nursing (ADON) stated through her investigation of Resident #1's fall, they determined Staff B failed to use a gait belt when assisting Resident #1 with walking in her room. Staff D stated they did extensive re education with Staff B on the proper use of a gait belt. Staff D stated the aide would have known how to transfer Resident as each aide received an aide sheet at beginning of each shift. The aide sheet informs the staff how each resident transfer, the use of assistance devices, and personal hygiene needs. Review of the personal file for Staff B identified a hire date of 1/3/24. She began her facility training on 1/8/24 and completed on 1/14/24. The file contained a form titled Use of the Gait Belt, which directed the aide they must use a gait belt at all times when transferring or walking a resident. Staff B signed the policy on 1/13/24, indicating she read the policy and understood her responsibility in the use of a gait belt. The Corrective Action Plan dated 1/26/24 indicated the facility reviewed and educated Staff B on the Gait Belt/Transfer Policy. The facility provided additional information on when to use a gait belt. The facility corrected the deficiency by implementing the following: a. The untitled form dated 1/26/24 reflected all facility staff read and understood the Gait Belt Policy & Procedure. b. The facility completed a Skills Fair on 3/19/24 that included education on the proper use of gait belts.

Based on clinical record review, observations, staff, and resident interviews the facility failed to ensure their call light system properly functioned for 2 of 4 resident neighborhoods observed (Community and Excellence) affecting 3 of 63 resident rooms (room [ROOM NUMBER], 4001 and 4010). The facility reported a census of 63. Findings include: On 7/15/24 at 11:45 AM observed Resident #3's family member attempt to activate the residents paddle call light in room [ROOM NUMBER] on the Community Neighborhood. Staff E, Certified Nurse Aide (CNA), present in the room at the time stated the call light didn't activate and come across her pager. The family member pushed the call light several times in attempts to summon staff but the light remained off. On 7/15/24 at 12:23 PM - 1:00 PM an observational tour with Staff F, Maintenance, revealed 2 call lights on the Community Neighborhood failed to work properly, room [ROOM NUMBER] and room [ROOM NUMBER]. Staff F stated nursing is responsible for the call light audits and will notify the Maintenance Department when there are malfunctioning call lights. He stated they have had occasional problems with the call lights and have had to reset/repair them. On 7/15/24 at 1:02 PM, Staff G, Administrator, stated the nursing staff completed call light audits on the remaining 3 neighborhoods that day and found 1 malfunctioning call light in room [ROOM NUMBER]. Staff G reported they asked the maintenance staff to fix the call lights. On 7/15/24, Staff H, Licensed Practical Nurse (LPN), denied knowing of any current malfunctioning call lights but stated they had issues in the past. Staff H reported she didn't get Resident #3's call light page at 11:45 AM that day. Staff H stated the only way to shut off the call lights after staff respond is to physically go into the resident's room and push the reset button. They can't shut them off any other way. On 7/15/24 at 1:30 PM Staff H explained she didn't get the page from room [ROOM NUMBER] at 11:45 AM that day. Staff H added it seemed like the call light system malfunctioned, the staff gave the residents either bells or air [NAME] to use until the completion of the call light system repair. She stated they fixed the system until the next time it malfunctions. Staff H indicated the staff put in a work order to Maintenance each time the call lights malfunction. Review of the Smart Call Resident Call Light System policy and procedure dated 1/5/23 revealed the Smart Call system is a wireless call light system that utilized pagers carried by nursing personnel each shift. Its the goal of the nursing department to answer resident's call lights, when activated, within 15 minutes.

Based on observation, policy review, and staff interview, the facility failed to follow the menu and substitute menu item that wasn't available in the Community household. The facility reported a census of 68 residents. Findings include: Review of the lunch menu for the Community household dated 8/9/23 revealed broccoli almond salad was to be served. Observation 8/9/23 at 12:02 PM revealed two separate containers of broccoli almond salad with temperatures obtained by the Certified Dietary Manager (CDM) of 50.5 degrees and 43.7 degrees and cottage cheese with a temperature of 42.4 degrees prior to serving. The CDM stated the items were not going to make the appropriate temperatures of 41 degrees or below prior to being served. The CDM then removed the items from the serving kitchen. Following distribution of the main lunch menu 8/9/23 at 12:36 PM, Staff D, Cook, reported she had spoken to the CDM and the plan was not to serve the broccoli almond salad as documented on the menu or the cottage cheese as it was too late and for staff to go ahead and serve the raspberry cake dessert. Review of the undated facility policy titled, Menu Changes, documented the following: a. Product on menu is unavailable, or for special events communication between cook and Certified Dietary Manager will take place b. Certified Dietary Manager is alerted and will contact Registered Dietician with substitute for approval. c. Replacement recipe with correct modifications will be provided to the cook d. In the event that the Registered Dietician is unavailable, the CDM will decide on a similar replacement and communicate with Registered Dietician to inform of this change. e. In the event a food item is not available, the CDM will provide an appropriate substitution During an interview 8/10/23 at 8:56 AM, the CDM acknowledged she did not follow the menu or substitute the broccoli almond salad as expected.

Based on observation, staff interviews, and policy review the facility failed to maintain adequate kitchen sanitation: failed to label and date food items; failed to store food in a sanitary manner; failed to maintain adequate temperature of the milk and cold items during meal service to reduce the risk of food-borne illnesses. The facility reported a census of 68 residents. Findings include: 1. An observation on [DATE] at 10:04 a.m. of the main food kitchen on the second floor noted moldy fruit in the walk-in cooler. A box of opened shredded lettuce and a box of shredded cheese along with 5 other boxes noted on the floor in the center of the cooler. The freezer noted to have 6 boxes of frozen food stored on the floor in the middle of the walkway. The dry storage area noted to have 4 boxes on the floor. An interview with the Certified Dietary Manager (CDM) on [DATE] at 10:06 a.m. reported that the facility just received a shipment of food and staff was still putting the truck away. She verbalized that the food is rotated first in first out. The walk-in cooler and dry storage cooler noted having food particles, crumbs, and sticky spots on both floors. An observation on [DATE] at 10:31 a.m. in the kitchen on the first floor Excellence wing noted Jello made in a container not labeled or dated. CDM informed the dietary staff the items needed to be labeled in the refrigerator. An observation on [DATE] at 11:10 a.m. in the kitchen on the first floor Excellence wing noted to have a prepared salad in the refrigerator not labeled or dated. In the refrigerator noted an expired milk with the expiration date of [DATE]. An observation on [DATE] at 11:15 a.m. in the kitchen on the first floor Progressive wing noted the milk in the ice cart to be served for lunch with the expiration date of [DATE]. An observation on [DATE] at 11:30 a.m. of the main kitchen on the second floor revealed the floors in the walk-in cooler and dry storage areas noted to have more food particles, crumbs, and sticky spots on the floors worse than noted on [DATE]. The walk-in cooler noted to have the same boxes on the floor in the center of the walkway. The freezer noted to have the 6 boxes of frozen food stored on the floor in the middle of the walkway. The walk-in cooler noted to have milk past the expiration date of [DATE]. Dry storage area is noted to have 4 boxes of dry food stored on the floor next to the shelves. During an interview on [DATE] at 1:10 p.m. the CDM verbalized she knew of the concerns with cold food not temping at proper temperatures, expired milk, and the moldy fruit in the walk-in cooler. She verbalized that they have looked into the possibility of contracting a milk company who supplies the milk and rotates the stock. She verbalized the need to further educate her staff on proper food temperatures and what to do if they don't meet the right temperature. The Food Storage Policy directed staff to store all dry food 6 inches off the floor. All items will be removed from original boxes and placed in appropriate storage. Food items will be rotated, first in first out. All staff will keep the kitchen clean and organized. The Food-borne Illness Prevention Policy directed staff for cold foods to be kept in a holding by way of an ice bath, temperatures to be 40 degrees Fahrenheit (F) or below and food above 40 degrees F will be thrown away. 46513 2. On [DATE] at 8:10 AM observed a half gallon of milk on the counter of the first floor, Progressive household kitchen, milk observed to be used for filling resident glasses during the breakfast service. The milk was used and placed back on the counter throughout the breakfast meal. On [DATE] at 8:37 AM observed Dietary Management Staff A and Dietary Management Staff B entered the kitchen during meal preparation, conversed message to staff in the kitchen. The staff entered the kitchen during meal preparation and serving, they did not wear hairnets. On [DATE] at 8:50 AM observed Staff C put the half gallon of milk into the refrigerator, requested the temperature of the milk. Staff C poured a glass of milk for temperature check and tempted the milk in the glass. The temperature of the milk was fifty-seven (57) degrees. On [DATE] at 9:25 AM Staff A relayed the expectation regarding milk is that the milk be kept in the refrigerator. Staff A relayed when a glass is poured, the milk container is put back in the refrigerator. Staff A acknowledged the expectation is hair nets should be worn when entering the kitchen area. On [DATE] at 10:10 AM Staff B acknowledged the milk temperature was not cold enough Staff B acknowledged hair nets should be worn in the kitchen. On [DATE] at 8:00 AM Staff A and Staff B revealed policy pertaining to dining room employees, policy titled, Policy on Uniforms and Personal Sanitation dated [DATE] documented the uniform consisted of hairnet to restrain hair and bangs. 48886 3. On [DATE] at 11:45 AM, observed a carton of skim milk located in the refrigerator on the second floor Family Plaza kitchen that had expired by two days, expired on [DATE]. Staff E indicated the milk was ready to serve to residents for lunch. On [DATE] at 12:25 PM, requested a temperature check of salad dressing served for lunch. The temperature of the salad dressing was 45 degrees. Requested a temperature check of cottage cheese left on the serving cart served for lunch. The temperature of the cottage cheese was 49 degrees. Requested a temperature check of cold broccoli salad left on the serving cart served for lunch. The temperature of the broccoli salad was 55 degrees. On [DATE] at 12:30 PM, Staff E acknowledged the cold food temperature should be 41 degrees or colder. Staff E indicated the intent to return the salad dressing, cottage cheese, and broccoli salad to the refrigerator for use the following day.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure residents remained free from abuse for 1 of 1 residents reviewed for abuse (Resident #35). The facility reported a census of 68 residents. Findings include: On 8/10/23 at 8:30 AM the Administer and Director of Nursing (DON) reported the facility just reported to the Department of Inspections and Appeals (DIA) allegations of abuse to a resident early this morning which was reported to the Assistant Director of Nursing (ADON) at 7:25 AM and the Administrator and and DON were in the process of investigating the incident. Resident #35's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) was not conducted because the resident is rarely understood, indicating severe cognitive impairment. The MDS documented the resident needed extensive assistance of one person with bed mobility, transfer, walking, and dressing. The MDS further documented the resident was total dependent of one person with toilet use, was frequently incontinent and had diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, and diabetes. Resident #35's Care Plan, initiated 5/26/23 recorded Resident #35 had cognitive loss, altered thought process related to history of stroke, and Alzheimer's dementia. The resident had self-care deficits, impaired mobility, and needed staff assist for activities of daily living. The Care Plan further documented the Resident had limited understanding and needed directives and cuing for daily decision making. On 8/10/23 at 11:05 AM, attempted to interview resident and resident was non-interviewable. An interview on 8/10/23 at 11:10 AM with Staff F, Certified Nurses Aide (CNA) reported around 5:55 AM on 8/10/23, Staff G, CNA and Staff F, CNA were walking past the Resident #35's room for report. Staff G, CNA reported to Staff F that early in the morning Resident #35 had hit Staff G, CNA and Staff G, CNA hit Resident #35 back. Staff F, CNA verbalized the nurse was off the floor getting report and another resident had to use the restroom so she reported it to the ADON at around 7:15 AM, Staff G, CNA then left the floor prior to Staff F, CNA going into the other resident's room. The facility's untitled, unsigned investigation report dated 8/10/23 reported the facility became aware of a situation with Staff G, CNA hitting Resident #35. Staff G, CNA is no longer in the building. The investigation included statements from Staff F, CNA who got the report of the situation, one staff member who worked with Staff G, CNA on overnight shift who was not aware of the situation, and a screenshot of a text message from Staff G, CNA to the DON. The text message documented Resident #35 smacked Staff G, CNA on the arm and Staff G, CNA responded involuntarily and popped the top of Resident #35's right hand. The facility investigative report documented Resident #35 was not able to be interviewed due to cognitive status, the Provider and Resident #35' s family was notified of the incident. A physical assessment was completed with no new injuries noted. Staff G, CNA was suspended immediately and the [NAME] police department was notified. Review of facility policy titled, Abuse Prohibition Policy & Procedure, dated March 2023 documented the following: Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. It also includes corporal punishment when used to correct or control behavior, including but not limited to, pinching, spanking, slapping of hands, flicking, or hitting with an object. The risk for abuse may increase when a resident exhibits a behavior(s) that may provoke a reaction by staff, residents, or others, such as: a. Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; b. Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; c. Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing; d. Taking, touching, or rummaging through other's property; e. Wandering into other's rooms/space; and f. Resistive to care and services.

Based on observations, clinical record reviews, and staff interviews, the facility failed to provide adequate nursing supervision for five of five residents reviewed (Resident #103, #25, #2, #41, and #16) to prevent a fall with injury. Resident #103 fell on [DATE], he had a severely impaired cognition level. No staff observed Resident #103's fall and took his word that he didn't hit his head. That night Resident #103 continued to complain of a headache all night. On [DATE], Resident #103 fell again documentation determined a skin tear to his right elbow with a bump on his head. At that time Resident #103 refused to go to the emergency room . On [DATE], his temperature went up and Resident #103 noted to have increased confusion. The family received notice and Resident #103 transferred to the emergency roiagnom on [DATE]. The Computed Technology (CT) Scan on [DATE] showed a large subdural hematoma. On [DATE], after Resident #103's unwitnessed fall, Resident #103 expired the hospital. During an appointment to the dentist, Resident #25 left in the facility van drove by a facility staff member. In the ride, Resident #25's wheelchair fell over sideways with her in it. An ambulance was called and the resident transported to the emergency room (ER). At the emergency room , radiology reports indicated a small brain bleed with a fractured (broken) clavicle (collar bone). Through additional clinical reviews, Resident #2 noted to have a history with falls and required staff assistance with transfer. On [DATE], Resident #2 noted to be on her bathroom floor complaining of pain to her fingers, left hip pain, and shortness of breath. After transferring to the hospital by ambulance, Resident #2 admitted to the hospital with diagnoses of multiple fractures to ribs on left side, a left pinky fracture, and a [CONDITION(S)] (urinary tract infection). When Resident #2 discharged from the hospital and returned to the facility, she had an additional diagnosis of a left pneumothorax (deflated or collapsed lung). The continued investigation determined that the facility failed to provide a safe transfer with a mechanical full-body lift for two out of two residents reviewed (Resident #16 and #41). Resident #16 got transferred by a temporary nurse aide (TNA) with a full-body mechanical lift without assistance from additional staff. During the transfer, Resident #16 fell from the full-body mechanical lift and hit her head causing an abrasion. During observations of Resident #41 and #16 determined incorrect usage of the appropriately sized sling (fabric material used to lift people up with the mechanical full-body lift. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 49 residents. Findings included: 1. Resident #103's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident #103's MDS included diagnoses of cancer, high blood pressure, and reduced mobility. In addition, the MDS identified Resident #103 required limited assistance of one person with bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, personal hygiene, and toilet use. Documentation showed Resident #103 frequently incontinent of urine and occasionally incontinent with bowel movements (BM). The Incident Note dated [DATE] at 3:30 AM indicated that a certified nurse aide (C.N.A.) found Resident #103 sitting on his bottom in front of his bed. Resident #103 reported that he took himself to the toilet to have a bowel movement (BM). Resident #103's description said he took himself to the bathroom and fell on to his bottom upon getting back into his bed. No injury or discomfort to the body. Physician notified by fax. The staff's action at the time of the incident included assessment of range and body for injury. Vital signs assessed, interviewed Resident #103, and assisted him back to bed. The door left open as an intervention to visualize the resident. The Interdisciplinary Notes dated [DATE] at 5:59 AM indicated that during the 10:00 PM until 6:00 AM shift, Resident #103 got up to the restroom by himself. The Interdisciplinary Notes dated [DATE] at 11:24 AM documented the staff provided nightly reminders to not get up to the bathroom by himself but he frequently did. Resident #103 noted to have stiff movements and refused suggestions to try Tylenol. The staff noticed an increase in urination for him. The Incident Note dated [DATE] at 12:15 AM indicated that the C.N.A. noted Resident #103's call light on. Once the C.N.A. answered the call light, they observed Resident #103 on the floor leaning against the door. Resident #103 denied knowing how he fell . The nurse noted two abrasions to his left occipital and a skin tear to his right elbow with no edges to approximate. Two staff members assisted Resident #103 into a standing position and walked him with a gait belt to the bathroom. Upon notifying the physician, the nurse received an order to start a neurological assessment (neuro) and the nurse requested a urinalysis (UA). The provider told the nurse to call Resident #103's provider in the morning and schedule and appointment. Resident #103 reported his age and explained he didn't feel the hospital could help him. The nurse notified the provider that he refused to be seen in the ER. Resident #103 received counseling multiple times to not get up alone but he couldn't repeat or voice understanding. Resident #103 did bump his head and had a 2 CM pink abrasion to his left upper occipital area. Resident #103 refused the suggestion to go to the ER replying that nope he didn't need to go there. The Interdisciplinary Notes dated [DATE] at 1:36 AM documented that Resident #103 had a skin tear observed to his right elbow measuring 1.5 centimeters (CM) by (x) 1 CM. Resident #103 did bump his head and had a 2 CM pink abrasion to his left upper occipital area. A mid left occipital abrasion noted measuring 1 CM x 1 CM. Resident #103 denied pain and refused to transfer to the emergency room (ER), replying that he didn't need to go there. The Interdisciplinary Notes dated [DATE] at 1:43 AM recorded that Resident #103's call light alerted the C.N.A. at 12:15 AM. As the C.N.A. entered the room, they noted Resident #103 on the floor leaning against the door. Active range of motion to the upper and lower extremities completed with a neuro sheet started. Resident #103 showed weakness but could walk after he got his bearings. At the time Resident #103 noted to be incontinent with urine. A skin tear observed to his right elbow measuring 1.5 CM x 1 CM. The nurse observed two areas to his left occipital, one 2 CM abrasion and one is a superficial slit to his left occipital. The nurse noted some bruising beginning around the sites. A UA completed due to recent increase in urination and the urgency to get up alone. Resident #103 only complained of pain to his right hand to his finger tip. The nurse attempted to call his Power of Attorney (POA) but got a computer-generated response that the caller wasn't accepting calls at that time. The Interdisciplinary Notes dated [DATE] at 3:16 AM recorded that Resident #103 continued to have increased incontinence and confusion. He needed assistance of one to two to walk into the bathroom. His temperature measured at 99 degrees. The Interdisciplinary Notes dated [DATE] at 7:17 AM documented that Resident #103 continued to have confusion, weakness, and increased incontinence. Breath sounds noted to be increased with increased congestion at the time. Resident #103 noted to not be able to answer questions correctly. After calling the provider, received an order to transfer him to the ER to evaluate and treat. After the nurse attempted to call the POA without a response, they called the brother to give an update. The Emergency Documentation dated [DATE] at 7:58 AM documented that Resident #103's blood pressure increased while in the ER. The ER staff gave 4 of [MEDICATION(S)] (pain medicine) and 10 of [MEDICATION(S)] (blood pressure medicine), which successfully controlled his blood pressure. As a preventive for [CONDITION(S)], Resident #103 received [MEDICATION(S)]. Resident #103's POA understood the diagnosis and his terminal status. The POA agreed to the plan for a hospice consult. The Diagnostic Results dated [DATE] at 9:52 AM indicated an impression of an acute subdural hemorrhages left supratentorial compartment. The left lateral subdural hemorrhage was large. There was an associated mass effect and midline shift. The Interdisciplinary Notes dated [DATE] at 2:58 PM indicated that Resident #3's POA notified the facility that he was admitted to the hospital. The History and Physical report dated [DATE] documented that Resident #103 fell on [DATE]. The hospital didn't have a report of the description of that fall. Since that fall, Resident #103 had worsening confusion. His POA explained that he normally could speak and knew his name, location, and year. At the time in the ER, Resident #103 would not answer any questions. The facility nursing staff noted cloudy urine two days ago and contacted his provider but had not heard anything back. At the nursing home, Resident #103's blood Oxygen (O2) saturation (sat) measured at 85 percent (%), but he didn't receive any O2. At the time of the evaluation in the ER, his O2 sat measured 97%. The ER nurses reported that they required the full strength of two staff to get him from the chair to his bed. The nursing home staff reported that he could ambulate with an assist of one person with his walker. Per his medication list, Resident #103 only took a baby Aspirin. Every time the staff attempted to touch, even gently, Resident #103 he moaned very loudly as in pain. The Assessment/Plan section indicated Resident #103 had a subdural hematoma, acute (buildup of blood on the surface of the brain). The Physician discussed the plan with the POA and decided on comfort measures due to Resident #103's terminal prognosis. The Neurosurgeon didn't think Resident #103 was a good candidate for surgical intervention. The Interdisciplinary Notes dated [DATE] at 8:27 AM recorded that Resident #103 passed away at 6:45 AM at the hospital. Resident #103's Care Plan identified an undated problem that he had a potential for injury related to a history of falls prior to admission, impaired mobility, often walked without a walker, even after education to use the walker with staff, use of a front wheeled walker and a history of dementia. The Care Plan lacked direction to the staff to make frequent rounds on Resident #103 or to ensure the door to his room stayed open. The [DATE] MAR (Medication Administration Record) revealed an order to give two tablets of Tylenol 325 MG (milligrams) every 4 hours as needed. The MAR only included one dose administered on [DATE] at 4:30 AM. The MAR contained no additional documentation after [DATE] of Resident #103 receiving Tylenol after his fall on [DATE]. On [DATE] at 8:56 AM, Staff BB, Licensed Practical Nurse (LPN), reported that Resident #103 rarely used his call light and often got up by himself. Resident #103 would say that he would do what he wanted, when he wanted. Staff BB explained that the staff should checked on him at least once every one to two hours. She explained that he transferred with an assist of one staff member and his walker. Staff BB reported that he had a history of falls and received education to keep his door open but often would not. When he fell on [DATE], the aide found him sitting on the floor with his back leaning on the door going into his room, He had some bleeding on the back of his head on the right occipital area. He had an abrasion with a little of bleeding, but he did not have a hematoma. She thought the abrasion was 2 cm x 2.5 cm. She informed the resident that he should go the hospital for x-rays as he had a bump on his head. He refused as he felt he was too old and did not have to go. On [DATE] at 11:28 AM, Staff O, C.N.A., reported that the staff should done rounds on Resident #103 every two hours. Staff O explained that he required assistance of one staff member with a walker and a gait belt. She reported that she thought that was his first fall that night. Staff O added that he did have fall interventions on his care plan that included use of the call light, which the resident never used but threw on the floor, and to keep paths clear for him. Staff O commented that they put gripper socks on him, kept the walker beside him, and kept the door open. The night he fell on [DATE], she heard him screaming. Upon getting to his room, she couldn't open his door as he leaned against it. Staff BB helped her open the door and they found him sitting on the floor. Resident #103 had blood on the door and a little on the floor, as he bled from the back of his head. Staff O thought he was trying to close the door and lost his balance. Staff BB and Staff O helped him back to bed with a gait belt. Staff BB checked his vital signs, checked his legs, and arms to make sure they could bend. He appeared to be in a lot of pain. After that he kept complaining about a headache. Staff O remembered that he kept refusing to go to the hospital. He kept saying he was [AGE] years old and didn't feel like he needed to go. Staff O recalled remembering him yelling and screaming that he was in a lot of pain afterward. Staff BB did not work the day he went to the hospital. On [DATE] at 1:24 PM Staff N, C.N.A, Certified Medication Aide (CMA), and restorative aide (RA), reported that the staff were to check on residents every two hours, and more frequently if the resident had a history of falls. She could not recall if the resident had a history of falls or what the Care Plan said regarding how he transferred. On [DATE] at 3:25 PM, the DON (Director of Nursing) reported the she didn't work when Resident #103 fell and she did not know what type of interventions he had on his care plan before the fall. On [DATE] at 3:57 PM, the Administrator reported Resident #103 had constantly tried to get up to go to the bathroom in the middle of the night. The Administrator explained that they had the physician check him for a [CONDITION(S)] (urinary tract infection). They tried to keep his door open, but he did not always like that, so he would get up and shut it. The undated facility policy titled: Fall Reduction Protocol documented the following: a. All falls will be discussed weekly during the Rehab Team meeting on Thursdays. b. The Care Plan Coordinator/Quality Assurance representative will summarize the falls that occurred the previous week. c. Current interventions will be initiated as deemed necessary by the Rehab Team. d. If a restraint is needed, least restrictive devices are considered first. e. Fall education is also provided at the mandatory CNA and nurse's meetings along with being addressed in the daily huddle meetings as needed. 2. Resident #25's MDS dated [DATE] identified a BIMS score of 00, indicating severe cognitive impairment. The MDS included diagnoses of anxiety disorder, [CONDITION(S)] (A-Fib, an abnormal heart rhythm), and high blood pressure. The MDS indicated that Resident #25 required total dependence of one person with locomotion on and off the unit. Resident #25 used a walker and a wheelchair for mobility devices. The Care Plan problem dated [DATE] indicated that Resident #25 had a self-care deficit related to an incontinence, [CONDITION(S)], and she required staff assistance with all activities of daily living (ADLs). The Care Plan lacked documentation regarding safety outside of the facility while in a vehicle. The Interdisciplinary Note dated [DATE] at 4:59 PM documented that at 11:00 AM, Staff A, Nurse Manager, received a call regarding an incident with Resident #25 in the wheelchair van going to her dentist appointment. The van hit a curb causing Resident #25's wheelchair became loose in the straps and she tipped over. The driver call an ambulance and Staff A went to Resident #25 to assess her. Resident #25 went to the hospital following the incident. At 4:30 PM the hospital called to report that the x-rays showed a small brain bleed. Resident #25 admitted to the hospital for observation and a neurological follow-up. The Interdisciplinary Notes dated [DATE] at 8:39 AM labeled as a late entry for [DATE] documented by Staff A, Nurse Manager, received a phone call regarding an incident with Resident #25. Staff A went to Resident #25 at the dentist's office in the wheelchair van. Upon arriving to the wheelchair van, Staff A observed Resident #25 sitting in the wheelchair. Staff H, Wheelchair Van Driver, stood at the front of the bus. The van contained pieces of the wheelchair broken on the floor. Staff A observed Resident #25's wheelchair not buckled with the safety straps. Staff H reported that he secured all the straps before leaving the facility. The ambulance crew reported that the wheelchair tipped to its side with Resident #25 laying on her right side. Assessment of Resident #25 determined impaired range of motion (ROM) to her right side and that she wouldn't lift her arm. Staff A explained that Resident #25's baseline ROM to her arms due to a history of arthritis to both shoulders. Staff A checked Resident #25's ROM. Resident #25 could lift her arms without difficulty close to her normal ROM, she denied pain. Resident #25 left by ambulance to the hospital. The CT Head or Brain without Contrast imaging results dated [DATE] documented minimal hyper density area in the right parietal lob, measuring approximately 9 x 7 x 10 millimeters (MM). The results represented a small area of hemorrhage. The XR Shoulder Min 2 Views R dated [DATE] indicated an impression of an interval appearance of a nondisplaced distal clavicle fracture. The hospital History and Physical dated [DATE] at 11:34 AM documented Resident #25's chief complaint as a fall with a subarachnoid hemorrhage. Resident #25 rode in a wheelchair van, when the driver hit a curb, causing her to fall. The facility nursing staff reported Resident #25 was properly secured in a wheelchair, but they didn't know if she fell out of the wheelchair or if the wheelchair fell over. Unable to determine head strike but the CT of Resident #25's head showed a small subarachnoid hemorrhage and intraparenchymal hemorrhage with some skin tears. Resident #25 received [MEDICATION(S)] (a medication used to treat active bleeding) in the Emergency Department as she took [MEDICATION(S)] (a blood thinner) for A-fib (an abnormal heart rhythm). The section labeled Differential Diagnoses reported diagnoses of intracranial hemorrhage, skull fracture, and skin tear. The Investigation regarding Resident #25's incident dated [DATE] revealed a description of the incident as told by Staff CC, Facility Companion. Staff CC explained that as they turned into the dentist's parking lot, Staff H drove over the curb and that caused the wheelchair to tip sideways. Staff CC reported that Staff H yelled oh no, which caused her to turn and see Resident #25 tipped over. Resident #25 asked for a cushion for her head. It happened so quick. Staff CC offered Resident #25 her coat, but Staff H found a cushion for under Resident #25's head. Staff CC went into the dentist's office and asked them to call 911. Staff H asked Resident #25 if she was ok but she didn't respond as she didn't hear well. The ambulance came within ten minutes. Staff CC couldn't recall if the straps were undone in the back of the bus. She said that several emergency medical staff (EMS) people tried to help so she tried to stay out of their way. The Investigation regarding Resident #25's incident dated [DATE] as told by Staff H explained that at approximately 10:45 AM he picked up Resident #25 with the 14-passenger bus to take her to the dentist. Staff H reported that as he got Resident #25 on the bus, he used the three straps to secure the wheelchair facing forward. Due to Resident #25 being so short, he didn't put the top seatbelt on her because it would hit her right across the neck and she leaned slightly to the right. Staff H explained that as he turned into the parking lot the back tire went up on a curb on the driver's side. The bus went up and then quickly down which jarred her in the wheelchair. The wheelchair flipped onto its right side with Resident #25 in it. Staff H reported that he pulled up to the door, stopped, and then check on her. Resident #25 responded to him. Staff H called his supervisor who directed him to call 911. Staff H sent Staff CC into the dentist's office to call 911. A nurse from the dentist's office came out to help with the situation. The Paramedics arrived and looked at Resident #25 but she didn't respond to them. Staff A arrived after Staff H's supervisor notified her of the incident. Staff A told the Paramedics to speak to Resident #25 on her left side, as heard better on that side. When questioned if she hurt, Resident #25 responded that her shoulder hurt. Staff A reported to the Paramedics that Resident #25 frequently complained of shoulder pain. Resident #25 responded yes to the Paramedics when they asked if she'd like to go to the hospital. The Paramedics lifted Resident #25 into her wheelchair and then used the lift to get her out of the van. From there the paramedics took her to the hospital, and Staff H returned her broken wheelchair to the facility. The Director of Plant Services inspected the bus's tiedown functions which operated correctly on [DATE]. Staff H received education on the proper use of the top seatbelt and told that he should never make a judgement call regarding a resident being too short. The Director of Plant Services told Staff H that the seatbelt must be used on all residents regardless of their size. The Director of Plant Services directed Staff H to get help from the Nursing department if a resident didn't sit correctly in their chair as someone could come on the bus before you leave to readjust the resident if needed. Staff H acknowledged and understood this direction. The Director of Plant Services audited the previous onboarding training information and determined that it included proper use of tie downs and the seatbelt straps. All of the facility drivers received and the Director of Plant Services would retrain all the drivers immediately to make sure they all understood the proper procedure in response to the incident. A review of forms submitted by the facility lacked documentation of review regarding the above education and lacked an attendance sheet signed by the facility drivers. The First Warning - Verbal dated [DATE] documented that Staff H received education that if any resident didn't get secured during transportation, it would result in immediate termination. The untitled form dated [DATE] signed by Staff H that he got trained successfully on how to properly secure a wheelchair using the necessary restraints. By signing that form, Staff H acknowledged that every time he transported a resident by wheelchair in a facility vehicle, he would correctly use the 3-point or 4-point restraint along with the lap belt. Failure to do so would result in an immediate termination. During an observation on [DATE] at 12:50 PM, Staff Z, driver demonstrated the securement of a wheelchair in the facility van used to transport Resident #25 at the time of the incident. Staff Z pushed the Director of Plant Services in the wheelchair on to the platform of the bus, locked wheelchair brakes, secured a safety belt behind himself as he stood behind the wheelchair, locked wheelchair, elevated platform, released the brakes to wheelchair, pushed the wheelchair into the bus, secured all four straps with hooks on to the front wheels, the back wheels, and secured the seatbelt across the director's chest. On [DATE] at 9:16 AM, Staff H reported that before the transport of any resident in a wheelchair, he should ensure the securement of the van straps on the floor to the wheelchair. Staff H admitted that he didn't place a seat belt across her chest. He reported that he received training from Staff AA, Driver, but he didn't remember receiving training on securing a seat belt before Resident #25's fall. Staff H explained that he did receive training on the securing the seat belt after the incident took place. Staff H couldn't recall the completion of a checklist to show what he received training on. Staff H added that approximately 50% of the residents he drove from the facility sat in a wheelchair. Staff H reported that the day the incident occurred, he pulled into the dentist's parking lot, the back wheel of the van hit the curb, and Resident #25's wheelchair fell over to the right. Staff H instructed Staff CC to ask the dental receptionist to call 911. Staff H explained that he called his supervisor who notified Staff A. Staff H added that Staff A came out to the location to look at Resident #25, then the ambulance took her to the hospital. On [DATE] at 9:33 AM, the Maintenance Supervisor reported that he learned about the incident after getting a phone call from Staff H. Staff H told him that Resident #25 tipped over when he hit a curb with the bus. The Maintenance Supervisor explained that it would be his responsibility or the responsibility of the Director of Plant Services to clear Staff H safe to drive residents. Another driver, Staff AA, trained Staff H for approximately a week after he started at the facility. The Maintenance Supervisor verified that there were 4 different points of restraints, two in the front and two in the back. The bus had straps with a rachet that secured the wheelchair to the bus. The Maintenance Supervisor added that to ensure this incident didn't occur again, the Director of Plant Services and him reviewed the procedure with the staff on how to properly secure residents in their wheelchairs when on the bus. On [DATE] 9:45 AM, the Director of Plant Services reported that he thought Staff H, had experience with driving residents in wheelchairs before he started at the facility. The Director of Plant Services added that when drivers transport residents in wheelchairs, they should make sure to hook all 4 ratchets on the wheelchair to secure it, then they should put a seatbelt across their chest. The Director of Plant Services didn't remember if the facility had a checklist on the bus for the drivers. The facility had a skills checklist for all new drivers to complete. The Director of Plant Services reported that he was pretty sure they did one on the resident. The trainers were responsible for checking off the new driver before they were put on their own. To ensure this incident didn't occur again, he brought the bus to his office building and checked to make sure the straps were working properly working. After inspection he determined that the straps were working properly. The Director of Plant Services explained they trained all the staff on how to properly tie down the wheelchairs. After the incident the Director of Plant Services wrote up Staff H. On [DATE] at 11:52 AM, Staff A reported that she received a phone call that a resident fell during their bus ride to an appointment. Staff A remarked that she went to assess the resident. Before she got there, the Paramedics moved Resident #25 off the floor and up in her wheelchair. The paramedics reported they found her still in the wheelchair on the floor without a seat belt in the wheelchair or secured across her chest. Staff A commented that she checked Resident #25's ROM. Her assessment determined her ROM to be at her baseline, she complained of pain to her right shoulder, her hand grips were strong and equal. Staff A didn't note any bleeding. Staff H respond when ask what happened that he thought maybe one of the straps came off during the transport. Staff A confirmed that Staff H should have made sure the securement of Resident #25 in her seat, that all the locks, and the bus straps were secured appropriately to the wheelchair. Staff A reported that it was the responsibility of the driver to ensure Resident #25 was secured. On [DATE] at 3:25 PM, the DON (Director of Nursing) reported she didn't work at the facility when the incident with Resident #25 and the bus occurred. The DON remarked that she would have expected the driver make sure that safely secure Resident #25 in the van. The DON assumed that they had the training to make sure the residents were secured in the van, by putting the wheelchair into the van and making sure the residents wore a seat belt. On [DATE] at 3:57 PM, the Administrator reported that she didn't work at the facility when the incident with Resident #25 occurred. The Administrator explained that she expected the driver to ensure to strap in Resident #25 correctly and to make sure that she had the seat belt across her chest. They asked Staff H why he did not use the seat belt. Staff H expressed to the DON that he didn't use it due to Resident #25's size and thought the seat belt would be too high on her neck. During a follow-up interview on [DATE] at 7:28 AM, Staff H reported that when the bus hit the curb and Resident #25's wheelchair tipped over. As Resident #25's wheelchair tipped over, she remained in the wheelchair. Staff H commented that Resident #25 responded to the question on how she felt, ok she was alright and did not appear to be upset or hurt. On [DATE] at 10:21 AM, Staff AA reported he had trained Staff H for approximately two weeks and but he didn't have any documentation related to the training with Staff H. Staff AA recalled training Staff H on how to put a passenger in a wheelchair into the van and how to properly secure the wheelchair. 1. The two straps should go on the frame with the wheelchair on the front and back. 2. Lock the wheels on the wheelchair. 3. Put the seat belt through the arms of the wheelchair and make sure it had been placed across the resident's body. Staff A reported that he had no knowledge of the incident with Resident #25 and didn't receive any re-education on the proper securement of residents in a wheelchair while on the van. During a follow-up interview on [DATE] at 10:51 AM, Staff AA, provided clarification and reported that the wheelchair van where Resident #25 fell had four straps to secure the wheelchair. During a follow-up interview on [DATE] at 12:55 PM, the Director of Plant Services reported that he didn't have a procedure guide regarding the transport of a resident in a wheelchair in the van, but he would type one up that day. The Director of Plant Services reported that he felt Staff H did not secure Resident #25's wheelchair properly, because if he had, the wheelchair would not have tipped over. 3. Resident #2's MDS assessment dated [DATE] identified a BIMS score of an 11, indicating moderately impaired cognition. Resident #2's MDS included diagnoses of cancer, heart failure, and diabetes. Resident #2 required limited assistance of one person with walking in room, walking in corridor, and toilet use. Resident #2 required extensive assistance of one person with dressing and bathing. The MDS identified Resident #2 as occasionally incontinent of urine and always continent of bowel. The Care Plan problem dated [DATE] identified Resident #2 as being at risk for injury related to a history of falls, impaired cognition, diuretic therapy, [MEDICATION(S)], noted to self-transfer, and walk by herself without calling for assistance. The Care Plan included the intervention dated [DATE] documented that on [DATE] Resident #2's fall intervention included to offer hour of sleep cares after dinner, assist to the bathroom, offer to get Resident #2 dressed for bed, and keep the bathroom door closed while not using. The [DATE] intervention directed staff to encourage Resident #2 to sit in her recliner until she was ready for bed and to wear gripper socks if she didn't wear shoes. The Care Plan lacked direction to make frequent rounds on Resident #2. The Interdisciplinary Notes dated [DATE] at 11:33 PM documented by Staff L, LPN, indicated the staff found Resident #2 lying on the bathroom floor on her left side with her knees slightly bent facing the toilet. Staff L assessed Resident #2, who

Based on staff interviews, clinical record reviews, and facility policy review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in an identified repeated concern during the current survey. The facility reported a census of 49 residents. Findings included: 1. The Facility's Self-Reported Incident dated 10/21/21, identified a fall in the facilities van. 2. Resident #41's Progress Notes dated 12/20/21, identified a fall from a full body lift. On 5/4/22 at 10:47 AM, the Administrator reported that the facility failed to address the fall (incidents) in the QAPI/ Quality Assurance and Assessment (QAA) process. The Quality Assurance (QA) Meeting Summary dated 12/9/22 and 4/14/22, failed to address falls. The QAPI Plan dated 6/14/21, a. Keep the systems functioning satisfactory and consistently including maintaining current standards of practice. b. To prevent deviations from appropriate care practices. c. To determine and identify any issues and concerns with systems in the facility. d. To correct any inappropriate care processes.

Based on observations, clinical record reviews, and staff interviews, the facility failed to ensure staff wore a face mask appropriately and eye protection during a time of substantial community transmission rate while serving food to Resident's #16, #29, #30, #33, #253, and #51. In addition the staff failed to ensure Resident #2 washed her hands after using the toilet. The facility identified a census of 49 residents. Findings include: 1. During screening on 4/27/22 at 7:40 a.m. Staff A, Nurse Manager, reported she could not remember the community transmission rate, but as of Monday (4/25/22) the staff received direction to wear a medical mask and eye protection. During a meal observation on 4/27/22 at 12:08 p.m., Staff B, Hospitality Coordinator, wore regular glasses with his medical face mask a half inch below his nose. Staff B prepared a plate of food and delivered it to Resident # 29, at table 2. Staff B returned to the kitchen, prepared another plate, and delivered the plate of food to Resident #253, at table 1 while continuing to wear his medical face mask below his nose and glasses without side eye protection. During an observation on 4/27/22 at 12:20 p.m. the Infection Preventionist sat in a chair supervising the dining room. Staff B wore regular glasses with his medical face mask below his nose removed a tray of ice cream from the freezer and delivered it to Resident # 30, sitting at table 3, Resident #253 at table 1, Resident # 33 sitting at table 5. After delivering the ice cream, Staff B went to table 4 to see if Resident #16 and #51 wanted ice cream. At 12:24 p.m. Staff B stated he needed to get a Magic Cup for a resident and left the 1A kitchenette. He returned at 12:26 p.m. wearing regular eye glasses with his medical face mask up over his nose. At 12:29 p.m. Staff B's medical face mask fell down below his nose, without fixing his medical face mask, he went out to deliver the supplement to the resident in the 1A dining room. The Infection Preventionist came to the kitchenette area and directed Staff B that he needed to put on his goggles. Staff B stated he took his goggles off, because the goggles were making his head hurt. At 12:30 p.m. Staff B went to find his goggles. He returned to the 1A kitchenette at 12:32 p.m. still wearing his mask below his nose and regular eye glasses. He stated he could not find his goggles and he had been all over the facility earlier that day. The Infection Preventionist directed him to go get a new pair of goggles. Staff B returned to the kitchenette at 12:35 p.m. wearing his medical mask over his nose with goggles covering his glasses. During an interview on 4/27/22 at 12:53 p.m. Staff B reported that he received direction by another staff member that morning he needed to wear eye protection in addition to his medical face mask. Staff B reported he had training on how to wear personal protective equipment (PPE). During an interview on 4/27/22 at 2:44 p.m. the Infection Preventionist reported a face mask and goggles were required to be worn that week. She reported she tried to signal to Staff B to pull up his face mask but he hadn't been looking at her. She stated she noted part way through the meal that he didn't have his eye protection on. During an interview on 4/27/22 at 2:45 p.m., the Director of Nursing (DON) reported eye protection and face masks were required to be worn at work when the community transmission rate was substantial to high. She expected the employee should have worn the medical mask correctly and worn goggles. She stated all the staff had training related to the correct use of PPE. A review of the infection control on 4/27/22 at 2:50 p.m. revealed the facility lacked documentation of an annual review of the infection control policies. During an interview on 4/27/22 at 2:57 p.m. the DON reported the facility did not have documentation of an annual infection control policy review. The DON expressed the community transmission rate as of 4/25/22 was 50.3%, indicating substantial. During an Interview on 4/27/22 at 2:58 p.m. in the presence of the Administrator, the Infection Preventionist reported when she had taken over the infection control, she didn't know of the requirement that the infection policies had to be reviewed annually. The Infection Control COVID-19 Policy, updated 3/1/22, provided by the facility documented COVID 19 spread in three main ways: 1. Breathing in air when close to an infected person who is exhaling small droplets and particles that contain the virus. 2. Having these small droplets and particles that contain virus land on the eyes, nose, mouth, especially splashes and sprays like a cough or sneeze. 3. Touching eyes, nose, or mouth with hands that have the virus on them. Spread is possible before people show symptoms. The virus that causes COVID-19 seems to be spreading easily and sustainably in the community in all area of the world. Given the congregate nature and residents served, nursing home populations are at the highest risk of being affected by COVID-19, and if infected, are at increased risk of serious illness. The Policy outlined PPE are protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission. This includes but is not limited to gloves, gowns, goggles, facemasks, or respirators. The Policy, under Source Control outlined as use of respirators, well-fitting facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking sneezing, or coughing. The Routine Infection Prevention and Control Practices During the COVID-19 Pandemic Policy dated 3/1/22 directed the use of source control, including the use of a well-fitting facemask or respirator will be expected at all times unless criteria is met that is later identified in this policy. The Policy directed health care personnel (HCP) will utilize source control at all times when the community transmission level are substantial to high, according to the Center for Disease Control and Prevention (CDC). HCP are expected to place source control on whenever in an area where they could encounter a resident, such as the hallway. The Policy further directed eye protection use in areas with substantial to high community transmission, all HCP will utilize eye protection during all resident care encounters. Eye protection may be used for extended periods of time, such as an entire shift. Eye protection consists of devices that cover the front and sides of the eyes to reduce the risks of splashes or sprays entering a person's eyes. Prescription eyewear is not considered adequate eye protection. The CDC Facemask Do's and Don'ts for Health Care Workers, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp/fs-facemask-dos-donts.pdf, directs to not wear a facemask under your nose or mouth. 2. Resident #2's MDS dated [DATE] identified a BIMS score of 7, indicating severe impaired cognition. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It also identified Resident #2 required extensive assistance of two people with bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, personal hygiene, and toilet use. The MDS indicated Resident #2 as occasionally incontinent of urine and bowel. Resident #2's Care Plan dated 3/25/22 identified a problem of a self-care deficit related to cognitive impairment related to Alzheimer's. Resident #2 could do some ADLs (activities of daily living) with cues and staff assist. It did not direct staff to provide hand hygiene to the resident after toileting. During an observation on 4/27/22 at 9:03 AM , Staff G, Certified Nurse Aide (CNA), assisted Resident #2 to the bathroom. After Resident #2 had a bowel movement (BM), she stood up and began to wipe herself before Staff G could assist her. After Staff G used the proper technique to cleanse Resident #2's rectal crease, she assisted her to sit in the wheelchair and proceeded to transfer her to sit in the recliner. Staff G failed to perform or offer hand hygiene to Resident #2 before leaving the resident's room. Interviews with the staff revealed the following: On 5/3/22 at 11:41 AM Staff J, CNA, reported when she helped a resident to the toilet and the resident did their own perineal care after a BM, before she could help, she would make sure that she cleaned the resident's peri-area and the resident's hands. On 5/3/22 at 11:54 AM, Staff I, Temporary Nurse Aide (TNA), reported when she took a resident to the bathroom, if they had a BM and they wiped themselves before Staff J could help, Staff I reported that she would make sure she cleaned the resident's peri-area and the resident's hands. On 5/3/22 at 1:32 PM, the DON (Director of Nursing) reported she expected that when a staff member help a resident to the toilet, then the resident had a BM, and she wiped herself before Staff J could help, the DON reported she would make sure she cleaned the resident's peri-area and the resident's hands.

Based on observations, interviews, and clinical record reviews, the facility failed to update Care Plans for 3 of 6 residents reviewed (Resident #2, #5, and #10) for unnecessary medication. The facility reported a census of 49 residents. Findings included: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected Resident #5 received an anticoagulant (AC) and diuretic medication for seven of the previous seven days over the look backperiod. Resident #5 received an opioid medication three of seven days during the lookback period. On 4/26/22 at 2:07 PM, observed Resident #5 resting in bed with her head of bed up. The Care Plan dated 3/25/22, failed to address the use of the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] (AC) 15 milligrams (mg) daily, and [MEDICATION(S)] (diuretic) 40 mg two times a day. b. [MEDICATION(S)] (opioid) 5 mg/acetaminophen 325 mg every 6 hours as needed (PRN). i. Resident #5 received 17 doses in April 2022. c. [MEDICATION(S)] (AA) 2 mg three times a day PRN. i. Used 21 doses of the [MEDICATION(S)]. 2. Resident #10's MDS assement dated 4/6/22, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected Resident #10 with a BIMS of 15, (intact cognition). Resident #10 took an AC for seven out of seven days in the lookback period. On 4/27/22 at 3:38 PM, observed Resident #10 sit in her recliner chair. Resident #10's Care Plan dated 4/18/22, failed to address the use of an AC medication, and what the staff were expected to monitor. Resident #10's April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/3/22 at 12:02 PM, the MDS/Care Plan Coordinator, stated she used the Care Area Assessments (CAA's) to determine what she addressed in the Care Plan. She said, she tried to include the high risk medications like [CONDITION(S)] medications, and diuretic medication with the risk of falls. She confirmed, she failed to include AC medications on the Care Plan. On 5/3/22 at 1:35 PM, the Director of Nursing (DON) reported she expected, AC and opioids addressed on the Care Plan. 2. Resident #2's MDS dated [DATE] identified a BIMS score of 7, indicating severe impaired cognition. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It also identified Resident #2 required extensive assistance of two people with bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, personal hygiene, and toilet use. The MDS indicated Resident #2 as occasionally incontinent of urine and bowel. Resident #2 used an anticoagulant for seven out of seven days in the lookback period. The Care Plan problem lacked information related to the use of an anticoagulant until 5/3/22. The Care Plan before 5/3/22 lacked directives regarding the use of [MEDICATION(S)] (a blood thinner), potential side effects to observe for, and report to the nurse. The observations of Resident #2 on 4/26/22, 4/27/22 and 4/28/22 revealed no evidence of bleeding or bruising. The March 30, 2022 to April 26, 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. 3/30/22 TO 4/26/22 [MEDICATION(S)] 6 mg on Tuesday and Friday with [MEDICATION(S)] 4 mg on Wednesday, Thursday, Saturday, Sunday, and Monday. b. 4/26/22 to 4/27/22 [MEDICATION(S)] 7 mg one time only. c. 4/27/22 to 4/28/22 [MEDICATION(S)] 5 mg one time only. d. 4/28/22 to 4/29/22 [MEDICATION(S)] 6 mg one time only. d. 4/29/22 to 5/2/22 [MEDICATION(S)] 6 mg on Tuesdays and Fridays with [MEDICATION(S)] 4 mg on Saturday, Sunday, Monday, Wednesday and Thursday. The facility policy titled: Baseline Care Plan dated 10/17 documented that the baseline care plan would be updated as needed.

Based on observations, record reviews and staff interviews the facility failed to ensure proper administration of insulin for 1 out of 1 resident (Resident #52) observed to receive insulin. The facility reported a census of 49 residents. Findings include: Resident #52's Minimum Data Set (MDS) assessment dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS indicated that Resident #52 required limited assistance of two people for transfers. Resident #52 MDS recorded that he received insulin injections for seven out of seven days in the lookback period. During an observation on [DATE] at 12:35 PM Staff T, Registered Nurse (RN), drew up 3 units of [MEDICATION(S)] insulin from a vial dated as opened on [DATE]. The vial included a discard date of [DATE] for Resident #52. Staff T committed to administering the 3 units of the [MEDICATION(S)] Insulin subcutaneously to Resident #52, until asked by the surveyor to go back and check the [MEDICATION(S)] insulin vial. Staff T looked at the [MEDICATION(S)] insulin vial, confirming the medication was outdated and it needed to be disposed. Staff T obtained a new vial of [MEDICATION(S)] insulin and administered the dosage from the new vial. Staff T reported being unsure of the policy regarding the expiration of opened insulin. Resident #52's [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 1:28 PM Staff U, RN/Unit Manager, reported that the policy didn't reflect when insulin should be discarded but according to the pharmacy, [MEDICATION(S)] should be discarded 28 days after opening the insulin vial. During an interview on [DATE] at 3:45 PM the Director of Nursing (DON) explained that she expected staff to check expiration dates on medication and not to administer the medication if expired. The DON added that insulin should be labeled with an open date and a discard date. The undated policy labeled Recommended Expiration Dates from Pharmacy directed the staff to refer to the insulin expiration date form. The insulin expiration date form indicated that [MEDICATION(S)] insulin expired 28 days after opening. The Insulin Administration Policy and Procedure - Insulin pen use and vials dated [DATE], directed staff to inspect vials with each use for proper color, clarity of insulin, and date opened to check for expiration. Page 8 of the package insert for [MEDICATION(S)] insulin revised ,d+[DATE] directed the user to discard opened vials of insulin after 28 days even if they still had insulin in them.

Based on record review and staff interviews, the facility did not always provide staff with a procedures to ensure accurate acquiring, recieving, dispensing, and administratering of all drugs and biologicals to meet the needs of each resident. The facility reported a census of 51 residents. Findings include: 1. Based on record review Resident # 2 had resided at Assisted Living Unit (on the complex) and transferred to the Nursing Home Facility on 01-25-2021 following a visit to the emergency room . During an interview on 09-29-2021 at 8:30 a.m., the Nursing Home director of nursing (DON) stated Resident #2's medications were transferred from her Assisted Living Unit to the Nursing Home Facilty via a facility transportation/driver. The facility transportation/driver gave the medicaitons to Staff A. Staff A kept the medications by her, but did not look at them. Staff A informed the oncoming nurse (of the medications) who placed the medications in the locked medication room. The DON stated the medications were returned to the Assisted Living unit on 01-27-2021. During an interview on 09-29-2021 at 11:35 a.m. Staff A stated she was the only nurse on duty on 01/25/2021. She stated she was aware that Resident #2 would be arriving to the Nursing Home Facility from her Assisted Living Unit (following an emergency room visit). Staff A stated she recieved calls from Assisted Living staff that they would be sending Resident #2's medications to the Nursing Home Facility. She stated the medications arrived shortly after the phone calls. Staff A stated she did not look at the medications from the Assisted Living Unit as she already had orders and medications from the hospital. Staff A stated the policy at the time was vague on the proper way to transfer medications from an Assisted Living Unit to a Nursing Faciltiy Unit. According to documentation on 01-28-2021 facility staff were educated on a new policy regarding how medications are accounted for when residents move from the Assisted or Independent Living Units to the Nursing Facility Unit. The new policy indicated that the discharging nurse would physically take medications to the building the resident would be moving to.

Based on observation, document review and staff interview the facility failed to maintain a proper functioning dishwasher to sanitize dishes. The facility identified a census of 52 residents. Finding include: During an observation on 10/5/20 at 2:50 p.m. Staff E, Dietary Cook, ran the dishwasher through two wash cycles. Staff E ran a chemical strip through on the third dish cycle and the strip failed to turn black showing appropriate chemical sanitation. The machine temperature gauge showed a wash temperature of 156 degrees and a rinse temperature of 164 degrees. Staff E reported she had received training but did not know what to do when the chemical strip failed. She reported the Dietary Manager would be at the facility soon. During an observation on 10/5/20 at 3:03 p.m., the Certified Dietary Manager, (CDM), of Health Services ran one dishwash cycle through, then placed a chemical test strip on a metal pan and ran through a full dish wash cycle. The wash cycle temped at 156 degrees. The rinse cycle temped at 168 degrees. The chemical strip failed to turn black to indicate proper chemical sanitation. During an interview on 10/5/20 at 3:05 p.m. the CDM, reported the chemical strips should turn black in the center to indicate the dishes have been properly sanitized. The CDM reviewed the dishwasher chemical strip documentation records. The CDM reported the chemical sanitation is to be tested every Wednesday, staff are to place an x in the column to show the chemical test strip has been done. On 10/5/20 at 3:10 p.m. the CDM reported they would start to using the three compartment sink to sanitize the dishes and resanitize the dishes used from lunch. She reported the dishwasher has a heat booster installed in the unit. The Surveyor observed on 10/5/20 at 3:12 p.m. the manufacturer posting on the Hobart Dishwasher read hot water sanitation wash temperature 150 degrees, rinse 180 degrees. Chemical sanitation wash temperature 120 degrees, rinse temperature 120 degrees. The untitled September and October 2020 documentation provided by the CDM documented the dish machine must be at 180 degrees on the final rinse. The am dishwasher must record the temperature before breakfast dishes. PM dishwasher must record temperature before supper dishes. Every Wednesday the AM dishwasher needs to record temperature using a temperature strip. The untitled, September and October 2020, document provided by the CDM showed the facility failed to document the test strip documentation from 9/2/10 through 10/5/20. The document showed gaps in the September 2020 documentation for the following September dates: 5, 10, 12, 15, 16, 19, 20, 24, 26, 27, 29, 30. The document showed gaps in the October 2020 documentation for the following October dates: 2, 3, 4. The untitled September and October 2020 document provided by the CDM documented the dish machine must be at 180 degrees on the final rinse. The am dishwasher must record the temperature before breakfast dishes. PM dishwasher must record temperature before supper dishes. Every Wednesday the AM dishwasher needs to record temperature using a temperature strip. The untitled September and October 2020 document, provided by the CDM, showed the rinse cycle temperatures for the AM and PM dishwash between 113 degrees to 123 degrees. The Hatco Corporation Electric Booster Water Heater Installation and Operating Manual, provided by the facility, documented the Hatco Electric Booster Water Heaters are designed for use with commercial dishwashers to boost the temperature of the regularly available hot water usually 110 degrees to 150 degrees Farenheit up to 180 degrees Farenheit. Water at 180 degrees can be used as sanitizing rinse water in commercial dishwashers in accordance with Health Codes, National Sanitation Foundation (NSF) Standard #5 and plumbing codes. The Service Record for the warewash dispenser on 12/3/2019 documented the operating conditions with a final rinse temperature of 130 degrees Farenheit. The Record documented water very hard at 20 grains. Booster tripped again. Advise to get repaired. Chemical tested okay. The Service Record for the warewash dispenser on 7/20/20 documented the final rinse temperature at 170 degrees Farenheit. The notes documented water tested very hard at 20 grains, replaced bulkhead and cleaned sinkbowl tip, ran and tested chemical and temperatures, rinse temperature not hot, booster heater tripped out. I reset but needs serviced, suggest to call(NAME)Tucker. The Service Record for the warewash dispenser on 9/15/20 documented the operating conditions of the machine with a final rinse temperature of 125 degrees Farenheit. The Service Record documented in the notes the (heat) booster tripped out again, needs services as soon as possible to sanitize dishes. Chemical tested okay. On 10/06/20 at 8:16 a.m., a local plumber reported he had received a call from the facility 10/6/20 at 6:00 a.m. to come look at the dishwasher. He reported he has adjusted the thermostat and ran through three full dishwash cycles. The wash cycle temperature showed 156 degrees Farenheit. The rinse cycle showed a temperature of 172 degrees Farenheit. He acknowledged the rinse temperature did not reach 180 degrees, but cited on the last test the rinse cycle went up to 220 degrees and he turned the water heater back down as they were afraid of burning out the unit. The chemical strip check turned black showing correct sanitation. The Dietary Supervisor reported they would continue to use the three compartment sink to sanitize the dishes and the heat booster unit would be replaced. During an interview on 10/6/20 at 10:23 a.m., the CDM reported she had checked with maintenance and the heat booster had not had any repairs since December 2019. During an observation on 10/07/20 at 10:48 a.m., the three compartment sink quaternary chemical tested at 400 parts per million appropriately. Staff observed placing dishes in the sink for sanitation for greater than 30 seconds for proper dish sanitation. During an interview on 10/08/20 at 1:18 p.m. the CDM reported the Administrator ordered the part on 10/6/20 to repair the heat booster for the dishwasher. She reported new staff are set up with a trainer and are expected to know how to read proper temperatures on the (dish) machine, do the chemical strip test and document. She would expect staff to ensure the dishes are sanitized. The Food Safety Requirement - Use and Storage of Food and Beverage Brought in for Residents, Food Procurement Policy, undated, provided by the facility documented the food service workers, cooks, dietary aides, dishwashers, food prep aides or any person(s) who are in the kitchen working with any type of food are responsible to adhere to the food safety requirements. The Policy noted many factors contribute to foodborne outbreaks in facilities. These factors apply not only to facility staff, but family and visitors as well. Several factors that cause pathogen growth include, but are not limited to: Contaminated equipment - equipment can become contaminated in various ways including, but not limited to: · Poor personal hygiene · Improper Sanitation, and · Contact with raw food The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, requires a warewashing machine and its components be operated in accordance with the machines's data plate. The concentration of the sanitizing solution, when required by the warewashing machine, shall be accurately determined by using a test kit.

Based on record review, staff interview, and resident interview, the facility failed to ensure that physicians orders and resident/family wishes for code status (life sustaining measures in the event of sudden death) matched in the resident record for 2 of 24 residents reviewed (Resident #53 and Resident #15). The facility census was 52 residents. Findings include: 1. Review of the EMR (electronic medical record) for Resident #53 on 10/7/20 revealed a current physicians order to Resuscitate with a start date of 9/18/20 (also the admitted for Resident #53). Review of the Profile Face Sheet in the EMR for Resident #53 also documented DNR Form . No (DNR - Do Not Resuscitste). Review of the paper medical chart on 10/7/20 for Resident #53, kept at the nurses station, has a sticker on the outside cover of their chart DNR and documents in the admission section of the chart revealed an IPOST (Iowa Physician order [REDACTED]. During an interview 10/8/20 at 8:58 am, Resident #53 stated that facility staff did ask on admission if they wanted anything done in the event that their heart stopped and the resident told staff they wanted no life sustaining measures taken. During an interview with the facility DON (Director of Nursing) 10/7/20 the surveyor asked for copies of the current physicians orders for Residents #53 and #15, when the copies were delivered to the surveyors the order to Resuscitate was gone for both residents, at 2:00 pm, immediately after receiving the requested copies, the surveyor asked the DON about this and they stated that the orders had not been updated in the computer (EMR) so they discontinued that order before printing the copies requested so the list of discintinued orders were printed for the surveyors and showed that the order to Resuscitate had been discontinued after the surveyor requested the copies and before the copies were printed. 2. Review of the EMR for Resident #15 on 10/7/20 revealed a current physician's orders [REDACTED].#15). Review of the Detailed Summary in the EMR for Resident #15 documented DNR Form: No and Resuscitate Level: Full. Review of the paper medical chart on 10/7/20 for Resident #15 has a sticker on the outside cover of their chart DNR. Documents in the admission section of the chart revealed an IPOST form filled out showing the resident did not wish to be resuscitated in the event they have no pulse and quit breathing. The wife signed the IPOST on 2/4/20, and the ARNP (Advanced Registered Nurse Practitioner) signed 2/5/20.

Based on clinical record review, observation, policy review and staff interview the facility failed to properly prime the insulin flex pen prior to insulin administration for 1 of 2 residents. (Resident #19) The facility identified a census of 52 residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] for Resident #19 identified the resident admitted to the facility on [DATE]. The MDS documented [DIAGNOSES REDACTED]. The MDS documented the resident received insulin injections 7 days a week. The physician's orders [REDACTED]. 1. [MEDICATION NAME] 100 units/mL subcutaneous solution, Give 5 units at breakfast (hold [MEDICATION NAME] for blood sugars less than 80) (Prime [MEDICATION NAME] using 2 units prior to giving) 2. [MEDICATION NAME] 100 units /mL subcutaneous solution, Give 10 units at lunch and supper (Hold [MEDICATION NAME] for blood sugars less than 80) (prime [MEDICATION NAME] using 2 units prior to giving) During an observation on 10/6/20 at 7:55 A.M., Staff A prepared the [MEDICATION NAME] Flex Pen for insulin administration by dialing the [MEDICATION NAME] to 2 units. Staff A stated she was priming the pen and pushed the button on the top of the pen returning the dial to zero. Staff A then applied the needle to the pen, dialed up the prescribed amount of insulin, cleansed the resident's skin and administered the insulin. The needle was not primed. During an observation on 10/6/20 at 11:43 A.M., Staff A prepared the [MEDICATION NAME] Flex Pen for insulin administration by dialing the [MEDICATION NAME] to 2 units. Staff A stated she was priming the pen and pushed the button on the top of the pen returning the dial to zero. Staff A then applied the needle to the pen, dialed up the prescribed amount of insulin, cleansed the resident's skin and administered the insulin. The needle was not primed. On the Medication Administration Record [REDACTED]. Review of the facility's Medication Administration Policy and Procedure did not address insulin administration. Review of the facility's Injection (Subcutaneous) procedure did not address insulin administration. During an interview on 10/7/20 at 10:35 A.M., the Director of Nursing (DON) stated they did not have a policy for insulin administration but would create one right now. Review of the Insulin Administration Policy and Procedures - Insulin Pen Use and Vials, dated October 2020 documented the staff should follow the manufacture instructions. The Patient Fact Sheet attached to the policy stated the needle is to be attached to the pen (Step 2), turn the dose selector to 2 units (Step 4), push the button all the way in until the dose selector returns to zero (Step 6), turn the dose selector to the number of units to be injected (Step 7) and then inject the insulin into the skin and push the button until it returns to zero (Step 8). During an interview on 10/8/20 at 1:03 P.M., the DON stated that they did not have a formal insulin policy prior to the one provided on 10/7/20. She stated they relied on nursing knowledge and did provide verbal education but nothing in writing. She stated she would expect nurses to follow manufacturer instructions even in the absence of a policy to do so. She further stated she would expect nurses to prime insulin needles.

Based on clinical record review, observation and staff interview, the facility failed to adhere to hand hygiene between glove changes, cleanse the whole peri-area during peri-care and remove dirty gloves before touching surfaces in the resident environment for 2 out of 2 resident (#2, 27) observed. The facility identified a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 9/23/20, for Resident #2 showed a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive loss. The resident required limited assistance for transfer, walking in room, personal hygiene and extensive assistance for dressing, toileting. The MDS documented Resident #2 as occasionally incontinent of bowel and frequently incontinent of urine with a [DIAGNOSES REDACTED]. The Care Plan, Category 5 Activities of Daily Living (ADL)/Rehab Potential noted a self-care deficit related to a history of [MEDICAL CONDITION] (TIAs), hypertensive disorder, idiopathic arthritis, migraines, [MEDICAL CONDITIONS] and urge incontinence. The Care Plan directed staff to provide the following care: · Clothing changes: assist of one twice a day and as needed. Start date 12/19/19. · Toilet use: assist of one to toilet (see Incontinence). Start date 12/19/19. · Peri-cares: assist of one with peri-cares twice a day, after toileting and as needed. Start date 12/19/19. The Care Plan, Category 6 Urinary Incontinence noted the resident is incontinent related to a history of TIAs, hypertensive disorder, idiopathic arthritis, [MEDICAL CONDITION], urge incontinence. The Care Plan directed the staff to provide the following interventions: · Toileting plan: assist to toilet every am (morning), before meals, after meals, at hour of sleep and as needed. Start date 2/5/20. · Maintain incontinent products in room. Replenish supply when low. Start date 2/5/20. The Care Plan, Category 13 Infection documented the resident at risk for infection related to coronavirus, flu, [MEDICAL CONDITION], incontinence, an aged immune system and directed the staff to perform proper immunological studies, titers, swabs, blood draws, etc. as ordered by the physician. Start date 5/19/20. During an observation on 10/07/20 at 1:39 p.m. Staff B, Certified Nursing Assistant, (C.N.A.), reported Resident #2 is very incontinent of urine. Staff B completed hand hygiene, donned gloves, and explained cares to the resident. Staff B removed and disposed of a wet large figure eight pad, removed gloves, performed hand hygiene and donned new gloves. Staff B cleansed the low abdomen, groin folds, bilateral thighs, and peri area. Staff B then touched the resident's walker with the dirty gloves to position in front of the resident so he/she could stand up from the toilet. Staff B continued to cleanse the buttocks and hips using the same gloves. After peri-cares were completed, Resident #2 ambulated back to the recliner touching the walker where Staff B's dirty gloves had touched the walker grips. Resident #2 had not been offered hand hygiene after toileting. 2. The MDS, dated [DATE], for Resident #27 documented the resident with a short and long term memory problem and moderately impaired decision making ability. The resident required limited assistance for dressing, personal hygiene and toileting with frequent incontinence of urine. The MDS listed a [DIAGNOSES REDACTED]. The Care Plan, Category 5 ADL Function/Rehab Potential identified the resident with a self-care deficit related to [MEDICAL CONDITION] Fibrillation (A-Fib.), [MEDICAL CONDITION], Irritable Bowel Syndrome (IBS), [MEDICAL CONDITION] (CAD), Dementia, Gastroesphageal Reflux Disease (GERD), Depression and Osteopenia. The Care Plan directed the staff to provide the following interventions: · Toilet use: assist of one as allows. Start date 5/19/20. · Peri-cares: assist twice a day and as needed. Start date 4/24/20. The Care Plan, Category 6 Urinary Incontinence documented the resident is incontinent related to A-Fibrillation, [MEDICAL CONDITION], IBS, CAD, Dementia, GERD, Depression and Osteopenia. The Care Plan directed the staff to provide the following care: · Use incontinent products for dignity. Start date 5/8/19. · Restock supply of incontinent products in room when supply runs low. Start date 8/28/19. · Assist to toilet in AM (morning), after meals, at hour of sleep and as needed. Start date 5/19/20. During an observation on 10/06/20 at 12:24 p.m., Staff C and Staff D, C.N.A.'s, perform hand hygiene and set up supplies on a clean barrier for peri-care. Staff C and D performed hand hygiene and donned gloves. Staff C cleansed the low abdomen, bilateral groin and peri-area. Staff C and D positioned the resident to the left side. The resident had been incontinent of a large amount of bowel movement (BM) across the full buttocks and above the gluteal crease. Staff C cleansed the right hip, right buttock and gluteal fold, then removed the BM filled pad. Staff C removed gloves, then donned a new pair of gloves without performing hand hygiene after removal of the dirty gloves. Staff D tucked a clean pad under the residents left hip. Staff D rolled the resident to his/her back and finished placing the brief. Staff C and D failed to position the resident onto the right side and cleanse the full left buttock and hip. During an observation on 10/07/20 at 11:10 a.m., Staff C and D provided care to resident #27. Staff C and D knocked, announced themselves, explained cares, performed hand hygiene and set up supplies on clean barrier. Staff D cleansed the low abdomen, bilateral groin and peri-area. Staff touched the resident's left hip and thigh with the dirty gloves to position the resident onto the right side. Staff D cleansed left hip, left buttock and gluteal fold, then removed a large figure eight urine soaked pad, then cleansed left buttock again. Staff D removed gloves and applied a new pair of gloves without performing hand hygiene. Staff D tucked a clean pad under the right hip and positioned the resident on his/her back to finish applying the pad. Staff C and D failed to position the resident on the left side to cleanse right hip and buttock. During an interview on 10/8/20 at 1:04 p.m., Staff B, C.N.A., reported the facility does quarterly peri-care and hand washing training/skill testing. She reported she knew that she had made a mistake when providing care to another resident on 10/7/20. She reported they are trained to cleanse the low abdomen, both sides of the front groin, peri-area, bilateral hips, buttocks and gluteal fold as part of peri-care. They are to do good hand washing with per-care. During an interview on 10/8/20 at 2:00 p.m., the Assistant Director of Nursing, (ADON), reported the C.N.A.'s receive peri-care training along with hand hygiene training every quarter which she personally oversees. She reported she uses a checklist to ensure proper training. She reported she would expect staff cleanse both hips and buttocks during peri-care and every place the brief touches. She reported she would expect the staff to do hand hygiene between gloves changes. The staff should not touch anything with dirty gloves on. During an interview on 10/12/20 at 9:59 a.m., the Director of Nursing, (DON), reported staff receive quarterly peri-care and hand hygiene training. She stated she would expect staff to cleanse the full buttocks and hips as well as all areas the dirty brief has touched. She reported staff should dispose of dirty gloves and sanitize hands before putting on a new pair of gloves with cares. Staff should not touch anything with dirty gloves. A Friendship Village Health Centers Perineal Care Return Demonstration Document, undated, provided by the facility identified the following within the Procedure Steps: · Correct peri-care technique female: spread labia, wipe one side then the other, then middle, wiping toward the rectal area, never wiping back and forth. · Correct per-care technique male: pull foreskin back if resident is uncircumcised. Clean tip of penis using a circular motion starting at urethra and working outward. Clean shaft of penis with firm downward [MEDICAL CONDITION]. Clean the scrotum. · Correct peri-care technique both: proceed to clean the rectal and buttocks area and anywhere incontinence product touched the skin. · Remove gloves before touching clothing, bed rail, curtain, etc. The Procedure failed to direct staff not to touch the resident's skin with dirty gloves. The Hand Hygiene Techniques Policy, undated, provided by the facility, listed guidelines which included: · Hand hygiene is a general term that applies to washing hands with water and plain soap or soap/detergent containing an antiseptic agent, or thoroughly applying an alcohol-based hand rub. · The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70-80%, prevent cross contamination and protect residents and health care personnel from infection. · Gloves or the use of baby wipes are not a substitute for hand hygiene. · The following list are some situations that require hand hygiene: after removing gloves or aprons, after contact with a resident's mucous membranes, body fluids or excretions. The Infection Control Policy, undated, provided by the facility documented the objective of this requirement is for the facility to develop a comprehensive Infection Control Policy that establishes a facility-wide system for the prevention, identification, investigation and control of infections of residents, staff and visitors that is based upon the facility assessment, best practices and regulatory compliance for the goal of quality of systems for care. A collaborative effort between the facility leadership, employees, resident/resident representative, facility staff, Medical Director and pharmacist is essential for success of the Infection Prevention and Control Program. It is the policy of Friendship Village that our Infection Prevention and Control Program (IPCP) is based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. The infection Prevention and Control Program includes a system of preventing, identifying, reporting, investigation, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards. The Infection Control Policy, written standards, policies and procedures for the Infection Prevention and Control program documents standards and transmission - based precautions are to be followed to prevent the spread of infections which includes hand hygiene to be followed by staff with direct care, handling resident care equipment and the environment.

Based on observation,clinical record review and staff interview the facility failed to ensure staff completed restorative programs as recommended by a therapist to prevent a decline in function for five of eleven residents reviewed (Residents #6, #5, #12, #13 & #8) The facility identified a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) assessment (MDS) for Resident #6 dated 5/18/16, documented [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two for bed mobility and transfer. An occupational therapy recommendation dated 1/25/16, included a directive for hand-over-hand assistance for all meals. With assistance to maintain grasp on spoon, resident will at times initiate scooping and bringing food to mouth. The form had been signed by the occupational therapist with the staff in-serviced signature line left blank. A second occupational therapy recommendation dated 1/25/16, included a recommendation to provide bilateral upper extremity passive range of motion to all joints, all planes x 10 repetitions with end range stretch for digits three times per week. Both lines for therapist signature and staff in-serviced had been left blank. The care plan dated 5/19/16, included a problem of Activities of Daily Living (ADL) functional/rehab potential, self care deficit related to weakness and increased confusion. The problem included no interventions for a restorative program. The same care plan included a problem of nutritional status/dehydration, impaired nutrition, potential for dehydration/impaired fluid maintenance. Resident confused and may need prompting to continue eating. The problem included no occupational therapy interventions for restorative dining. A review of the restorative program documentation revealed the resident had recommended restorative program exercises only completed on the following dates: For February 3rd (once in one week), 9th (once in one week), 14th (once in one week), 26th and 27th (twice in one week). For March (Zero times in one week), 9th (once in one week), 13th (once in one week), 22nd (once in one week), 28th and 30th (twice in one week). For April 6th (once in one week), 10th (once in one week) and 22nd (once in one week). The resident had no restorative documented the last week of the month. For May (last two weeks) 17th, 21st (twice in one week) and 22nd (once in one week). On 6/8/16 at 6:45 a.m., Staff B and Staff C completed morning cares for the resident. Observation revealed no range of motion exercises. During observation of the breakfast meal on 6/8/16 at 7:12 a.m., the resident sat in the dining room in a wheel chair and received a bowl of cold cereal with a cut up banana in it. The resident ate slowly, holding a spoon with closed fists. Cold cereal frequently spilled off the spoon and on to the table. On 6/8/16 at 7:20 a.m., the resident continued to eat, with no staff present in the dining room. The resident frequently coughed. The resident had a two handled cup with a straw and attempted to take a drink but could not. At that time Staff A (Registered Nurse, RN) entered the dining room and sat beside the resident. Staff A took a spoon and fed the resident with no hand-over-hand method. The resident sat close to the table, with the table height at the residents upper chest. Staff A briefly continued to feed the resident with no hand-over-hand, then left the table. O 6/8/16 at 7:30 a.m., the resident received a plate with scrambled eggs and a whole donut. No staff sat beside or assisted the resident. The resident picked up the donut with the left index finger and thumb and took a small bite. On 6/8/16 at 7:35 a.m., the resident attempted to eat the scrambled eggs with a fork and had visible difficulty. The resident ' s hands remained clenched in a fist while the resident attempted to pick up the fork with both fists. The resident held the fork awkwardly between the left thumb and side of the index finger while trying to grasp with the right hand. The resident dropped the fork on the plate. The resident then picked up the donut with the left thumb and side of index finger and took a bite. The resident dropped a piece of the donut. As the resident attempted to eat, they leaned toward the table, with the chin approximately four inches from the plate. On 6/8/16 at 7:42 a.m., Staff A sat beside the resident and stated they had a few minutes and could help the resident with the eggs. Staff A then used the fork to feed the resident the eggs with no hand-over-hand technique. On 6/8/16 at 12:07 p.m., the resident sat in the dining room in a wheel chair. The resident received a lunch plate with minute steak and cauliflower and cheese sauce. Staff C (CNA) sat beside the resident and gave the resident a bite of food on a fork. Staff C used no hand-over-hand technique. On 6/8/16 at 12:15 p.m., Staff C left the table and Staff B (CNA) then sat beside the resident. Staff C continued to use a fork to feed the resident and used no hand-over-hand technique. On 6/8/16 at 2:00 p.m., Staff A stated they had tried the hand over hand at one point but it didn't really work so staff just allow the resident to eat what they can and feed the resident the rest. On 6/9/16 at 8:35 a.m., Staff J (Assistant Director of Nursing/MDS Registered Nurse) assessed the residents range of motion to the bilateral hands on the surveyor request. The resident did not have full extension ability of the fingers on either hand. At that time Staff J stated the resident ' s hands were definitely more tighter than they had been when last assessed. At that time Staff J stated there had been no documentation any of the staff had at any time attempted to use the recommended hand-over-hand technique to assist the resident to feed themselves. 2. The Minimum Data Set (MDS) assessment for Resident #5 dated 3/29/16, documented [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of one for bed mobility and transfer. The MDS documented the resident had no range of motion limitations to the upper extremity, and impairment on one side of the lower extremity. A comparison MDS dated [DATE], documented the resident had no limitations to the upper or lower extremity. The care plan dated 4/5/16, included a problem of activity of daily living (ADL) functional/rehab potential, self-care deficit related to limited weight bearing status to left as evidenced by need for assistance with all transfers, mobility and ADL tasks. The problem included no intervention for a restorative program. A physical therapy nursing/restorative recommendation dated 5/20/16, included a recommendation for a restorative aide two to three times per week for bilateral lower extremity strengthening including: -hip flexion -hip abduction -hip extension -knee flexion -knee extension The recommendations provided no specific number of repetitions or sets for the exercises. The form had been signed by the physical therapist, and the line for signature of staff in-serviced left blank. A review of the facility restorative book revealed the resident had no restorative documentation sheet. On 6/8/16 at 8:55 a.m., Staff D (Restorative Aide, RA) verified they had been the assigned RA for the Landing, and stated they had only been able to do restorative with residents in the building one day a week and on their other scheduled days had been pulled from the restorative position to work as an aide on the floor. Staff D stated the CNAs were to be doing range of motion with all residents when doing cares but not sure if they did. Staff D stated they only had one day a week to do recommended restorative programs with all residents in the Landing (two floors), and it had been that way for months. Staff D verified there were typically over 30 residents to try to complete restorative programs in the one day. During interview with Staff B (Certified Nurse Aide, CNA) on 6/8/16 at 1:50 p.m., the surveyor asked if CNAs did any range of motion or restorative exercises with first floor residents in the Landing. Staff B stated the CNAs routinely did restorative exercises with only two residents on the first floor, but not resident #5, #6, #12 or #13. At 2:10 p.m., Staff D stated that if a resident had been on a restorative program they would have a documentation sheet in the restorative book. 3. The MDS for Resident #12 dated 4/13/16, documented [DIAGNOSES REDACTED]. The MDS documented the resident required limited assistance of one for ambulation and dressing. The MDS documented the resident had no impairment to the upper extremity and impairment to one side of the lower extremity. The care plan dated 4/5/16, included a problem of ADL functional/rehab potential, self care deficit related to dementia. The problem included no intervention of a restorative program. A physical therapy restorative recommendation dated 6/6/16, included a recommendation for a restorative aide two times per week, for the following: a. Bilateral lower extremity seated exercised x 10 repetitions (provide visual cues and encourage to slow down). b. Hip flex, LAQ (unknown abbreviation per Staff J 6/9/16 at 9:15 a.m.), hamstring curl, hip abduction, hip adduction and ankle circles. The form had been signed by the physical therapist with the staff in-serviced signature line left blank. A review of the facility restorative documentation book revealed the resident had no restorative documentation sheet. 4. The MDS for Resident #13 dated 3/23/16, documented [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of one with bed mobility and transfer. An occupational therapy recommendation dated 7/16/15, included a recommendation for an upper extremity exercise program to include the following: a. Upper extremity restorative (machine) x 5-10 minutes with minimal resistance b. 1# dowel bar exercise bilateral upper extremity two sets, twelve repetitions: shoulder, horizontal abduction and elbow. The form had been signed by the occupational therapist but the staff in-services signature line had been left blank. The care plan dated 4/5/16, included a problem of ADL functional/rehabilitation potential related to weakness to legs and poor balance and stability as evidence by multiple falls in assisted living. The care plan included no interventions for a restorative program. A review of the facility restorative book revealed no documentation sheet for a restorative program for the resident. The facility Director of Nursing (DON) stated during interview on 6/9/16 at 8:14 a.m., they had been aware of a problem with the restorative programs and residents were not receiving restorative exercises as planned. The DON stated the facility planned on putting an ad in the newspaper to hire restorative staff but had not done so yet.

Based on observation, clinical record review and staff interview, the facility failed to ensure safety interventions were implemented and adequately addressed for one of six residents (Resident #1). On 7/7/15 staff failed to transport Resident #1 safely in his/her wheelchair. Staff interviews and record review determined the resident's care plan lacked adequate safety provisions which resulted in Resident #1's fractured leg. The facility also failed to use electrical equipment in a safe manner and failed to secure hazardous items and medications to prevent accident hazards. The facility census was 68 residents. Findings include: 1. The Minimum Data Set (MDS) with a reference date of 5/19/2015 identified [DIAGNOSES REDACTED]. The MDS reported the resident required two staff assistance for bed mobility, ambulation, and transfers. The form indicated the resident had upper and lower extremity impairments on one side. According to the assessment, the resident scored a 2 on the Brief Interview for Mental Status (BIMS) cognitive test, which identified severe cognitive impairments. Review of the resident's care plan dated 2/18/15 and revised on 5/19/15 revealed a potential for injury. The care plan directed staff to use a wheelchair for ambulation, transfer the resident with assistance of two staff and gait belt and ensure safe dry footing. The care plan also directed staff to follow physical therapy and occupational therapy (OT) recommendations. The care plan did not identify specific physical therapy safety recommendations. An OT Therapy Progress note revealed the care giver had been educated on the foot box on the resident ' s wheelchair. The care plan updated on 7/11/15 directed staff to make sure the resident is in good sitting posture when pushing his/her wheelchair. During review of the facility incident report, nurse's note with the report dated 7/7/2015, at 8:00 p.m. The note indicated that the resident had hit the left top of foot when going into room. According to a Physician Visit Form Out of Office dated 7/11/15, Resident #1 required an evaluation for the injury sustained on 7/7/15 and extensive bruising of the left lower leg. The X-ray revealed an oblique fracture of left tibia. The FAX to the resident ' s physician documented the resident had been seen in the ER (emergency room ) on 7/11/15 regarding an injury from 7/7/15 or extensive bruising to left lower leg. The X-ray showed oblique fracture of left tibia. The ER doctor gave orders for Tylenol with Codeine PRN (as needed) and an orthopedic referral. The resident ' s left lower leg continue showed bruising from the top of the foot to below left knee level. The swelling had decreased at the top of the foot but the skin around the shin showed moderate swelling with redness and warmth. In a phone interview on 8/12/15, at 8:05 a.m. Staff B, (Certified Nurse Aide) acknowledged that on the date of the incident Staff A requested assistance repositioning Resident #1. She observed the resident from behind, sitting in the wheelchair in the TV room. Staff B stated, from her view she observed the resident sitting in the wheelchair and assumed the left leg was on the foot rest or Staff A would have repositioned him/her properly. When she pushed the resident's wheelchair through doorway, and she heard a loud cracking sound and went to get the nurse. The nurse had been busy with other residents and came later. Staff B state there had been a red area on the top of left foot approximately half the size of a credit card. During an interview on 8/11/15, at 2:35 p.m. Staff A (CNA) acknowledged that on the date of the incident she observed the resident sitting in the TV room. The resident had slouched down in the wheelchair and she asked Staff B to help her pull Resident #1 up. Staff B stated let ' s just put Resident #1 to bed. Staff A reported Staff B pushed the resident ' s wheelchair as the resident remained in the slouched positioned with his/her left leg off to the side. Staff A stated, when Staff B pushed the wheelchair through doorway, she heard a loud noise and informed Staff B the resident ' s foot hit the door frame. During an interview about the incident on 8/11/15 at 10:00 a.m. the Acting Director of Nursing acknowledged the resident's left leg is flaccid (no muscle tone) due to a stoke. She stated his/her wheelchair had been adapted with a padded food rest so the resident ' s foot (feet) would not slip off the foot rest. The ADON reported if the resident had been slouched and his/her foot (or feet) had not been on the padded foot rest; this could have contribute to the resident ' s injury. The ADON stated the resident cannot control movement of his/her left leg. The ADON confirmed that on the date of the incident the resident had slouched down in chair and feet were not placed on foot buddy, the left foot hit the door frame. The ADON stated staff would know the correct positioning by following the resident ' s care plan. The surveyor requested the care plan directives that addressed the padded foot rest, proper positioning and brace (leg immobilizer). The ADON stated that Staff B (Certified Nurse Aide) had been the staff involved with the incident on 7/7/2015, the staff person no longer worked at the facility. In an interview on 8/11/15 at 11:50 a.m. the Care Plan Coordinator stated Resident #1 ' s care plan lacked direction for staff to use the foot buddy safety device (the foot buddy is a padded foot rest that holds feet in place and prevents slipping off wheel chair foot rest). She stated the foot buddy device had not been documented on the care plan. The Coordinator reviewed the care plan dated 7/11/15, which directed proper positioning when pushing the wheelchair. The Coordinator stated the care plan is unclear and proper positioning should include both feet being positioned on the foot buddy foot rest. The Coordinator also reviewed the direction for the use of the brace on the resident ' s left leg and stated there was no guidance on the care plan for staff to use the resident ' s immobilizer. She stated the pocket care plans utilized daily by staff did not reflect the proper positioning or use of immobilizer to the resident ' s left leg and these would be updated. The updated care plan dated 8/11/15 directed staff to use the foot buddy (for positioning) when in the wheelchair with the upright posture, and the resident ' s feet on the foot buddy. The care plan informed staff to not push the wheelchair with the resident ' s legs crossed or with his/her feet/legs outside of the wheelchair frame. 2. On 8/11/15 at 6:30 a.m., observation revealed a medication cart sat near the nurses station in the Pavillion. The cart sat unlocked and no staff had been present. The cart contained multiple bubble packs and bottles of resident medication. At that time the surveyor notified Staff M, Licensed Practical Nurse stated the cart should not have been left unlocked and proceeded to lock it. 3. During environmental tour of the Pavillion on 8/12/15 at 8:30 a.m., observation revealed a large pair of scissors in an unlocked drawer of a chest in a resident lounge area near an ice cream maker. Observation during the same tour revealed large cracks and uneven surfaces in the cement in a fenced in patio area. At that time Staff L, Maintenance verified the area could be hazardous to residents ambulating in the area. During the same tour, observation revealed a large pair of scissors on an open plastic container on the side of a medication cart which sat next to the dining room. At that time, the facility Acting Director of Nursing verified both buildings had cognitively impaired residents and scissors should be locked up. 4. During the environmental tour of the Landing on 8/12/15 at 2:00 p.m., observation revealed an ice machine on the first floor of the Landing with an ice machine plugged into an extension cord which laid underneath of the ice machine. At that time Staff L stated the cord should not be used for the ice machine and should not be lying underneath of it. During the same tour, observation revealed a large pair of scissors in an open plastic container on the side of the medication carts on both the first floor of the Landing, as well as the medication cart of the second floor of the Landing. 5. During observation of the Landing facility on 8/10/2015 at 12:35 p.m., found a portion of concrete missing along the patio sidewalk located adjacent to doorway of resident lounge area. The concavity measured 11 inches long, by 3 inches wide, by 1.5 inches deep. At 12:36 p.m., observed a square flower pot on the floor by the resident's dining room. The flower pot had loose trim and jagged edges around upper rim and down the side of the pot, and trim edges felt sharp. At 12:40 p.m., found the cabinet doors on the first floor of the kitchenette and resident dining area unlocked and unattended. Inside the unlocked door, observation revealed the following items stored, and labeled keep out of reach of children: a. One - 1 pound (lb) container of PDI super sanicloth wipes. The warning label indicated to avoid eye and skin contact, and to contact poison control or doctor for medical treatment. b. One - 8 ounce (oz.) bottle of Gentell body lotion. The label indicated contents for external use only and to avoid eye contact. c. One - 4 oz. bottle of Convatec aloe vesta skin conditioner. The label indicated if product swallowed, to seek medical help or consult poison control. d. One - 1 quart can of Eliminator fast acting foaming spray. The material safety data sheet (MSDS) indicated exposure to product caused skin and eye irritation. The MSDS advised a physician should be contacted immediately if product swallowed or skin/eye irritation persisted. e. One - 16 oz. can of Betco air freshener. The label advised to seek medical attention if eye or skin irritation developed, or if product inhaled or ingested f. One - 17 oz. can of Betco stainless steel cleaner. The MSDS advised to avoid eye contact, and to contact poison control if product ingested. During interview 8/10/15 at 12:50 p.m., Staff E, Registered Nurse, stated the cabinet doors in kitchenette normally locked unless staff present in the area. Staff E identified 4 of 15 cognitively impaired and ambulatory residents at the facility.

Based on observation, record review and staff interviews, the facility failed to plan for and direct the nursing services in order to increase safety measures and provide adequate supervision to ensure against hazards to Resident #1. Resident #1 displayed increased confusion prior to sustaining a fall which resulted in a major injury (fractured hip). Complications arose following a fractured hip repair which required further hospitalization as a result of a pulmonary embolism (blood clot in lung). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 8/5/13, documented an initial admission date of [DATE]. The MDS documented [DIAGNOSES REDACTED]. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. The MDS documented the resident required extensive assistance of two for bed mobility and transfer, and extensive assistance of one to ambulate in room. The MDS documented the resident had a fall in the last month prior to admission, and a fall in the past 2-6 months prior to admission. An initial fall risk assessment (no date), documented the resident scored a 15. A score of 15 reflected the resident to be at high risk of falls. The form documented the resident had a history of [REDACTED]. The Care Plan dated 8/7/13, included a problem of falls. The problem documented the resident had a potential for injury related to falls as evidenced by weakness, [DIAGNOSES REDACTED]. Resident lacked judgement for safety with transfers and ambulation. The problem included the following interventions: a. Monitor for adverse reactions to medications and notify MD if observed. b. Assure that call light is within easy reach in room at all times. c. Encourage resident to wear eyeglasses. d. Instruct with verbal cues when transferring/ambulating. e. Maintain clean, uncluttered environment. f. 1/2 side rails up x 2. g. Use wheel chair for mobility. h. Assure safe dry footing. i. Encourage slow transitions for lying to sitting/sitting to standing. j. Fall risk assessment quarterly. A Physical Therapy (PT) recommendation dated 8/13/13, requested staff please ambulate with patient to and from bathroom, all meals, activities beauty shop, etcetera with gait belt, contact guard assistance of one, gait belt and wheeled walker. May use wheel chair for very long distance only. The signature line to document staff had been in-serviced on the recommendation had been left blank. An interdisciplinary (ID) note dated 8/13/13 at 12:10 a.m., documented the resident had called the nurses ' station on the phone and asked what time they were leaving. The nurse went to check on the resident and the resident had been walking around their room with a suit case and dressed for the day stating their bag had been packed and they were ready to go. The nurse attempted to re-orient the resident to the time and inform the resident, he/she had all night to still sleep. The nurse informed the resident they were going to sleep now and in the morning they would come and help them get ready and take them to breakfast. The nurse offered the resident assistance to get ready for bed again. The resident stated they were ready and might as well stay dressed. The nurse informed the resident several times of the hour. An ID note dated 8/15/13 at 3:17 a.m., documented the resident walked to the nurses ' station per self. Confused. Resident asked what their friends phone number was to call and see if they were picking the resident up for church. Re-oriented resident to time of day. Assisted resident to a chair in the nurses ' station and gave a cup of coffee. Resident repeated question about calling their friend and church several more times. An ID note dated 8/15/13 at 10:42 a.m., documented the resident had an unsteady gait when walking with Occupational Therapy (OT). An ID note dated 8/15/13 at 1:29 p.m., documented Occupational Therapy (OT) recommended the resident be assisted with toileting and cleaning self and applying incontinence products. An OT recommendation dated 8/15/13, documented the resident needed assistance with toileting daily, with precaution for decreased balance. A line on the form for staff signature to show staff had been in-serviced on the recommendation had been left blank. An ID note dated 8/20/13 at 1:29 p.m., documented the resident self- transferred three times, observed walking down the hall unattended, reminded resident the importance of waiting for help and resident smiled and continued walking. Gait belt applied and resident assisted back to room. An ID note dated 8/21/12 at 10:47 a.m., documented the resident continued to get up without assistance, remind resident to wait for assistance but resident remembered only for a short time then gets up again (without assistance). An ID note dated 8/24/13 at 11:00 a.m., documented the resident had been reminded two times to wait for assistance. Up walking halls two times per self. An ID note dated 8/25/13 at 5:26 a.m., documented the resident up in halls ambulating two times during night. Resident used walker on one occasion and no walker at another time. Resident worried about getting to church this night. Had been awake since 1:30 a.m. Re-oriented and re-directed several times. An ID note dated 8/25/13 at 12:51 p.m., documented the resident continued to get up by self- multiple times that day, had a beer at lunch, confused that morning, wanted to go to church, took few times until resident understood they had church on Monday not Sunday. An ID note dated 8/26/13 at 12:18 a.m., documented on 8/25/13 on hourly room checks at 11:30 p.m., the resident had been found on the floor on door side of bed with head and upper body underneath bed and lower extremities bent in upward position and out from under bed. Previous shift reported resident had been sitting in bed with eyes closed on their last check of resident around 9:30 p.m.. Resident stated they did not remember what happened. Asked resident if having pain and resident held on to left hip area and rubbing top of left lower extremity with hand. Noted facial grimacing and moaning with any movement. Vitals 148/71, pulse 116, Temperature 98.0, respirations 18, oxygen saturation 95% on room air. Resident call light within reach on bed but resident did not use call light to obtain assistance. Ambulance called and transferred resident to emergency room . Intervention added to care plan to keep room door open at all times as when entered room to find resident on floor room door had been closed. Visual checks already performed on resident hourly per facility policy. An ID note on 8/26/13 at 2:45 a.m., documented the resident had been admitted to a local hospital with a femoral neck fracture in the left leg. An operative report dated 8/26/13 documented the resident had a [DIAGNOSES REDACTED]. The report documented the resident underwent [REDACTED]. An ID note dated 8/29/13 at 9:35 p.m., documented the resident had been readmitted to the facility from the hospital with skilled level of care. An ID note at 10:32 p.m., documented the resident would be moved to a room when they came back from the hospital which would have the resident in staff's closer view due to fall risk. A history and physical dated 8/31/13, documented the resident had been at a high risk for deep vein thrombosis/pulmonary embolism considering the resident had recent surgery. A physician consultation dated 9/1/13, documented the resident had been brought to the hospital with shortness of breath. The patient recently had hip surgery after a hip fracture with a fall. A physician consult dated 9/2/13, documented the resident had been admitted to the hospital with [REDACTED]. A physician consultation dated 9/3/13, documented that the resident had fallen on the 26th of August 2013, and sustained a hip fracture. The resident had been admitted to the hospital and underwent surgical repair. The resident had been placed on thromboprophylaxis and underwent surgery on the 26th of August for the hip. However during the hospitalization and with prophylaxis goal anticoagulation the resident ended up developing gastrointestinal hemorrhage necessitating an endoscopy. Patient ' s anticoagulation was then discontinued. The patient then developed pulmonary embolism. An ID note dated 9/4/13, documented the resident again readmitted to the facility from the hospital with a [DIAGNOSES REDACTED]. During an interview on 9/18/13 at 8:00 a.m., the facility Director of Nursing (DON) stated no interviews had been completed by the facility with staff related to the incident because the resident had been found on the floor and had been on hourly checks. Clinical record review revealed no documentation of hourly checks performed on the resident. Record review did show hourly safety flow sheet checks completed for twenty-four hours on 7/30/13, 8/29/13, and 9/4/13. At 10:00 a.m., the DON stated there had been no regularly documented checklist for hourly safety checks on the resident and the staff just did the checks as part of their routine. The DON stated there had been no written policy on residents with a high risk of falls, the facility would just update and follow the care plan. The DON stated the resident did have a fall in the assisted living apartments prior to being admitted to the facility in July of 2013, but staff did not do incident reports in that area. The DON stated the safety flow sheet checks for 7/30/13, 8/29/13 and 9/4/13 had been started on the dates the resident was admitted to the facility then readmitted after the two hospital stays, in which case the policy had been to do hourly checks for 24 hours. During an interview at 10:11 a.m., Staff A (Licensed Practical Nurse) stated on the day of the incident they were doing their first set of rounds and at about 11:30 p.m., they went into the residents room and found the resident on the floor. Staff A stated the interventions for the resident had been to keep the call light in reach, do hourly rounds and keep the bedside table next to the bed, which it had been. Staff A stated the resident had used the call light in the past but when the resident got stronger the resident felt like they had been bothering staff, so had been educated on the use of it. Staff A stated they would guess the resident had gotten up and closed the door. Staff A stated they start hourly rounds at about 10:30 p.m., after report. Staff A stated they had thirty-some residents to check on so it may be longer than one hour between each check depending on what they had to do in various rooms. On 9/18/13 at 11:00 a.m., Staff B, Certified Nursing Assistant was interviewed and stated she had worked the night shift the night of the incident. Staff B stated second shift usually did rounds at 9:30 p.m. and third shift usually did rounds at about 11:30 p.m., after they did report and got waters (fresh water for residents). During an interview with Staff C (CNA) on 9/18/13 at 2:00 p.m., she stated they had been the staff person who put the resident to bed the night the resident fell . Staff C stated the residents call light had been in reach, the bed had been in a low position, the 1/2 rails had been up, the night light on, and the resident had been reminded to use the call light. Staff C stated the door had been left open upon exiting the room but the resident would get up and close the door. Staff C stated maybe just checking on the resident more would have been an intervention which could have prevented the fall. Staff C stated the resident had been put to bed at about 9:00 p.m. the night of the incident. The facility DON stated on 9/19/13 at 10:04 a.m., there had been some thought of moving the resident to a room closer to the nurses ' station but there had been none available. The DON stated the facility had now implemented every thirty minute checks for residents with a high risk of falls and a sheet would be placed in the room for staff to document on. The DON stated it probably would have been good to have that in place prior to the incident but hindsight is always twenty-twenty. The DON stated the resident had been placed on hospice care.

Based on record review, resident and staff interviews, the facility failed to plan for one of four residents to receive adequate supervision and assistance to and from the bathroom (Resident #1). Resident #1 required staff assistance with transfers and interviews determined he/she waited 15-20 minutes for staff to respond to his/her call light and finally took him/herself to the bathroom and fell . Resident #1 fractured his/her right shoulder and sustained a hematoma to his/her head. The facility reported a census of 32 residents. Findings include: According to documentation in the medical record, Resident #1 had [DIAGNOSES REDACTED]. Documentation in the facility MDS (Minimum Data Set) assessment form dated 2/13/13, indicated Resident #1 scored 13 or 15 on the BIMS (brief interview for mental status) indicating intact cognition. The assessment determined Resident #1 required one staff person to assist him/her with bed mobility, transfers and to use the bathroom. Resident #1 also needed one staff person to assist him/her with personal hygiene, when dressing and when walking in his/her room. The assessment revealed Resident #1's balance during transition and walking as not steady and only able to stabilize with staff assistance when moving from seated to standing position, when walking, when turning around, when moving on and off the toilet, and during surface to surface transfer (transfers between bed and chair or wheelchair). The individual plan of care dated 11/15/12 identified falls as a potential problem for Resident #1. The care plan interventions included the following: assure call light is in easy reach at all times verbal cues when transferring and ambulating encourage to ask for assistance do not leave in the bathroom unattended keep slippers out of sight (added 2/14/13) offer toileting between 6:00 and 7:00 pm (added 3/14/13) The resident's ADL (activities of daily living) care plan dated 2/14/13, documented he/she needed assistance to the toilet in the morning, before meals, at bed and as needed. The care plan directed staff to ensure the resident's call light was in reach and for one staff to transfer the resident with a gait belt. The incident report dated 12/28/12 revealed staff found Resident #1 on his/her floor beside the bed. The resident had sat on the side of the bed and reached for his/her slippers and slid off the side of the bed. The incident report identified the care plan will direct staff to keep the resident's slippers out of reach when in bed. The assessment after the fall revealed the resident had no pain or injury after the fall. The interdisciplinary notes dated 12/28/12 revealed the resident's call light had been on (no indication of how long) and the resident had been reminded to call and wait for assistance for transfers and for reaching items. The incident report dated 2/5/13 revealed staff found the resident sitting on the floor at the side of his/her bed. The resident stated he/she had been looking for his/her slippers and slid off the bed. The report identified Resident #1 stated he/she was not hurt. The interdisciplinary notes dated 2/5/13 revealed at 7:25 a.m. the resident had been found on the floor and staff assisted the resident to the bathroom. The resident reported he/she had been looking for his/her slippers. The notes revealed no changes implemented after this fall. The interdisciplinary notes dated 2/5/13 at 4:40 p.m., revealed the staff observed the resident's significant other assisting him/her out of bed. The significant other and resident were informed this was not safe and to only allow staff to assist with transfers. The interdisciplinary notes dated 3/14/13 indicated staff found Resident #1 lying on the bathroom floor at 7:30 p.m. with his/her head up against the wall. The resident's right arm had been positioned slight underneath resident. Staff noted Resident #1 unable to move right arm and when assessed Resident #1 complained of pain to the right shoulder, rating pain at a 10 on a scale of 0-10. The nurse completed vitals and recorded Resident #1's blood pressure at 202/108. The notes documented the nurse asked the resident what happened and Resident #1 reported at the time of his/her fall, he/she had the call light on. Resident #1 reported he/she waited for a long period of time and nobody came, so he/she figured he/she would take him/herself to the bathroom. Resident #1 stated when he/she got to the bathroom he/she went to pick up the slippers off the bathroom floor and fell over. Staff transferred Resident #1 to the emergency room . The interdisciplinary notes dated 3/15/13 documented the nurse called the hospital to check on Resident #1. The notes identified the resident had been admitted with a [DIAGNOSES REDACTED]. The hospital report dated 3/14/13 identified Resident #1 fractured his/her right shoulder. The finding documented the following: there is evidence of a surgical fracture of the neck of the humerus with medial superior displacement of the humeral diaphysis. The humeral diaphysis is approximately displaced by 1 cm (centimeter) medial and impacted with cephalad displacement also by approximately 1 cm. There is a cortical fracture fragment interposed is in the diaphyseal region of the humerus. There is a subtle nondisplaced greater tuberosity fracture. During an interview on 04/02/13 at 3:11 pm, Resident #1 stated he/she had the call light on "awhile", but could not specify the exact time, so he/she just went to the bathroom by his/her(self). Resident #1 stated once in the bathroom he/she found the slippers and bent over to pick them up and fell . Resident #1 added that he/she felt the facility did not have enough help. During an interview on 04/02/13 at 4:30 pm, Staff A stated Resident #1 usually used the call light to ask for assistance. Staff A stated that evening there were only 2 staff (one nurse and one nursing assistant) scheduled to work (for 15 residents) and they usually have 2 nursing assistants. Staff A described 3 other residents in the area that needed attention, one resident in the process of sliding out of a chair, and the other two as higher fall risks than Resident #1. Staff A stated the only nursing assistant on the unit was assisting a resident with a shower. Staff A stated she estimated Resident #1's call light to have been on between 15 and 20 minutes, but she felt the other residents were at a greater risk of falling, and there were no other staff available to answer Resident #1's call light.

Based on observation, record review, and staff interviews, the facility failed to implement intervention (s) to provide adequate supervision to prevent falls for 2 of 11 residents (Residents #17 and Resident # 6). The facility also failed to maintain an environment as free from hazards as possible. The facility identified a census of 70 residents. Findings include: The hospital emergency room (ER) progress note dated 1/6/13 documented Resident #17 experienced multiple falls without any history of syncope (fainting) or presyncope, hypertension (high blood pressure), extreme age, multilevel degenerative disease of the spine and history of reported dizziness and short term memory impairment. The Minimum Data Set Assessment tool with a reference date of 1/14/13 revealed the resident displayed severe cognitive impairment and required extensive assist of one staff to for transfer and walk in his/her room. The resident's (undated) facility Admission Care Plan directed staff to encourage/instruct use of the call light, keep call light in reach and Physical Therapy referral as needed. The resident's Fall Risk assessment dated [DATE] scored the resident at 16 points. Above 10 or above points indicated high risk for falls. The PT recommendations signed by a Physical Therapist on 1/8/13 directed staff to assist the resident with one staff, a gait belt and a front wheeled walker during transfers. The recommendations documented the resident as, "confused and impulsive." The Nurse's Notes dated 1/7/13 at 9:51 p.m. documented the resident arrived at 3:30 p.m. from the hospital per wheelchair. The resident admitted due to history of falls and hypertension. The resident required assist of one with walker and was unsteady. Staff documented the resident as confused, alert to time and person and currently resting in bed with call light in reach. The Nurse's Notes dated 1/8/2013 at 8:59 a.m. documented the resident as very anxious and confused. The resident kept trying to stand on his/her own. Student sitting with resident at present. Blood pressure 188/88. The nurse called the resident's physician regarding the resident's anxiety and elevated blood pressure. The physician ordered Xanax 05. milligrams (mg), three times daily as needed for anxiety. The Nurse's Notes dated 1/8/13 at 11:16 a.m. documented the resident was alert with confusion and attempting to get up several times. The resident complained of back and leg pain (pain med given). An entry on the same day at 3:27 p.m. documented the nurse sent a fax to the resident's physician to inform him of the resident's bruises and falls sustained when the resident was in Assisted Living. The physician directed staff to observe the resident. The Nurse's Notes dated 1/12/13 at 7:12 p.m. documented staff sent a fax to the resident's physician requesting scheduled anxiety med due to the resident receiving his/her as needed anxiety medication every day since his/her arrival to facility. The Nurse's Notes dated 1/14/13 at 2:03 p.m. documented the physician ordered staff to administer Xanax 0.5 mg twice daily. An incident report dated 1/14/13 at 3:40 p.m. documented staff heard Resident #17 calling for help and found him/her on the floor in front of the bathroom. The resident sustained [REDACTED]. The report revealed staff sent the resident to the emergency room . A facsimile (fax) the staff sent to the physician dated 1/16/13 documented Resident #17 seen byER on [DATE] and returned to facility with ER staff stating no fracture. On 1/15/13, facility received a fax sent by the (hospital) Radiology Department showing minimally displaced superior and inferior pubic rami fracture. An X-ray report faxed from the hospital on [DATE] but dated 1/14/13 revealed the resident sustained [REDACTED]. During an interview with Staff F, Licensed Practical Nurse (LPN), she described the resident as confused and anxious, although very sweet. She stated the resident had a hard time staying on one place for very long. She also stated the resident attempted to transfer by him/herself a lot and she often kept the resident by her medication cart with her at night because the resident would frequently became more anxious as the night went on. Staff F reported on 1/14/13, staff told her Resident #17 was on the floor. Staff F stated she went into Resident #17's room and completed an assessment on the resident prior to assisting him/her up. Staff F reported the resident was confused at the time of the fall and initially denied any pain during the assessment. After the resident was taken to the bathroom, he/she did complain of pain and staff sent him/her to the ER for evaluation. During an interview on 3/7/13 at 9:42 a.m., Staff H, Certified Nursing Assistant (CNA) reported she had checked on the resident after report (2:00 p.m.) and he/she was "fine". Staff H left the hallway that contained the resident's room as she needed to obtain the supplies to pass ice water to the residents. When she returned, another CNA had pulled the resident's emergency call light. Staff H entered the resident's room and saw the resident on the floor by the bathroom. Staff H reported the resident used to like to get up on his/her own and that staff tried to check on the resident every hour. Staff H reported sometimes it was hard because so many call lights were on at the same time. Staff H stated the resident used her call light when first admitted , but then became more anxious and confused and seldom used the call light. During an interview with Staff I, CNA on 3/7/13 at 10:30 a.m., she verified she usually worked the day shift (6:00 a.m. to 2:00 p.m.). Staff I reported the resident was frequently anxious. Staff took the resident to the bathroom numerous times, helped him/her lay in bed and the resident would then want to be up right away and transfer independently. Staff I stated that maybe the resident wanted someone there all the time as she would smile and be happy and hold staff's hand when staff were with him/her. Staff I reported the resident didn't use his/her call light. During an interview with Staff G, LPN on 3/7/13 at 10:38 a.m., she reported she routinely worked with Resident #17. She reported the resident was often nervous, couldn't get settled and could not always tell staff what he/she needed. Staff G reported she wasn't aware how often the resident attempted to transfer independently. She also reported the resident did not use the call light. During an interview on 2/15/13, the MDS Coordinator reported at the time of the fall on 1/14/13, Resident #17 did not seem to understand how to use the call light. She reported the resident's room was located around the corner and down the hall from the Nurse's Station and was not visible from it. During an interview with the Director of Nursing (DON) on 2/19/13 at 1:39 p.m., she was in the facility and on 1/14/13 when the resident fell . She reported the resident walked fairly well with his/her walker, although he/she forgot to use it the day of the fall. She also reported Resident #17 did not use the call light, but the roommate would put it on for him/her when the Resident #17 started to stand up. The DON stated the resident got up by him/herself frequently. On 3/7/13 at 4:16 p.m., the DON showed the surveyor the room where the resident resided prior to the fall on 1/14/13. Observation revealed the room was at the end of the hall and farther away from the Nurses Station than any of the other resident rooms. During another interview with the Director of Nursing on 3/8/13 at approximately 10:45 a.m., she stated they were not very happy about the location of the resident's room when he/she was admitted and at the time of the fall (1/14/13), but it was the only room left when the resident arrived. She reported as soon as another room became available (2/6/13), the staff moved the resident so he/she could be closer to the Nurse's Station. During an observation on 1/29/13 at 8:30 a.m., Staff J, Certified Nursing Assistant (CNA) provided cares for Resident #17. The resident stated, "I'm real disappointed with myself. I can't control this leg." 2. The admission Profile Face Sheet dated 07/29/11 identified Resident #6 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS)assessment tool dated 01/02/13 identified the resident with a cognitive score of 4 out of 15, indicating severe impairment with making daily decisions and required extensive assistance of 1 staff person for transfers, bathing and toileting. The resident was noted to have 2 falls with injuries this past quarter. The resident's Care Plan dated 01/11/13 identified a potential for injury/falls as evidenced by a history of falls since admission and noted interventions that included the following: a. Remind/encourage the resident to ask for assistance with transfers/ambulation when needed. b. Keep the room door ajar to help monitor. c. 12/14/12-Keep walker in front of resident. d. Keep walker within the resident's reach at all times. e. 03/01/13-1 staff to assist with ambulation using the walker and gait belt. Observation on 03/04/13 through 03/06/13 at many times revealed the walker always placed in front of the resident when sitting in the wicker chair in the television room. Record review of the resident's Incident Report dated 12/14/12 at 6:50 p.m. revealed the resident walking in the hall without the walker, lost balance, fell to the knees and hit the head on a pillar. The resident's right knee exhibited a 10 by 9 centimeter (cm) bruise, the left knee exhibited a 5 by 5 cm. bruise and the right eyebrow exhibited a 2 by 1 cm, raised by 0.5 cm. bruise. The report stated the resident's care plan was modified. Record review of the resident's Incident Report dated 02/26/13 at 9:30 a.m., revealed the resident was on the floor in front of the chair in the sunroom (also television room), which was unusual for the resident to get up. The resident sustained [REDACTED]. The report stated the resident's care plan was modified. Record review of the Nurse's Notes dated 12/14/12 at 6:50 p.m., revealed the resident was observed walking without assistance in the hallway next to the dining room, and staff was unable to reach the resident before the fall. It was observed the resident lost their balance, fell to their knees, and hit their head on the pillar in the dining room. The resident received bruises. The new intervention is to keep the resident's walker within reach of resident. The resident's care plan noted on 12/14/12 to keep the walker in front of the resident. Record review of the Nurse's Notes dated 02/26/13 revealed the resident was seen by the kitchen staff on the floor at 9:30 a.m. The resident may have sustained a bruise on the right knee and will be monitored. The walker was not in front of the resident, as per care plan, and staff will be instructed on fall intervention for all shifts, not just second shift. During an interview on 03/04/13 at 10:00 a.m., Staff C, Licensed Practical Nurse, stated the resident's second fall was due to the fact the walker was not in front of the resident. During an interview on 03/06/13 at 9:17 a.m., Staff A, Registered Nurse, noted care plan changes for residents are communicated during shift report and extend a few days, to make sure everyone is alert to the new changes. The new changes may be in the Aide's Communication book, however some staff cannot read English, so they have to make sure that staff person has been verbally informed. There is no sign off with staff's initials to know if all the staff are aware of the new changes. During an in interview on 03/07/12 at 1:45 p.m., Staff E, Direct Care Worker (Certified Nursing Aide) stated the walker must be directly in front of the resident and heard that is why there was a second fall, as the care plan was not followed. The Direct Care Worker's have a written care plan sheet to carry around for all resident cares and noted that was written in for cares on this resident. 3. An observation on 3/4/13 at 9:10 a.m. revealed a medication cart in a resident hallway left unlocked, unattended, and with medications on top of the cart. The surveyor opened drawers of the medication cart to verify it was unlocked. The facility Director of Nursing (DON) came to the cart and then looked for the nurse in charge of the medication cart. The DON located Staff D (LPN) in a resident room at the end of the hall and around the corner. During an interview with Staff D at the time of the observation 3/4/13, she stated she left the medication cart in a hurry to attend to a resident calling out for help. Staff D and the DON acknowledged Staff D should have locked the medication cart before the staff member left it.

Based on observation, clinical record review and interviews the facility failed to plan for and direct the nursing services to ensure residents with weight loss received the necessary services to promote weight gain or prevent weight loss for 4 of 4 residents (Residents #6 #1, #2 and #9; and failed to implement the care plan to address Resident #6's significant weight loss or implement new intervention to address his/her impaired nutritional needs. The facility identified a census of 70 residents. Findings include: The suggested parameters for evaluating significance of unplanned and undesired weight loss are: Significant loss: 1 month 5 percent (%) 3 months 7.5% 6 months 10% 1. The admission Profile Face Sheet dated 07/29/11 identified Resident #6 with [DIAGNOSES REDACTED]. Record review of the Nurse's (Interdisciplinary Notes) notes dated 5/20/12 noted the resident continues to refuse dietary supplements. According to the Minimum Data Set (MDS) assessment tool dated 1/02/13, Resident #6 score of 4 on the Brief Interview for Mental Status (BIMS) cognitive test. A BIMS score of 0-7 indicates the individual had severe cognitive impairments for making daily decisions. The assessment identified Resident #6 required extensive assistance of 1 staff person for transfers, hygiene, bathing, and toileting. The MDS noted the resident's weight at 89 pounds, and revealed no weight changes. The assessment identified Resident #6 did not have swallowing disorders, no weight changes, and required limited staff assistance with eating. The Care Plan dated 10/11/12 identified Resident #6 had nutritional impairments due to diabetes, [MEDICAL CONDITION] and a poor appetite. The plan identified the resident receives health shakes with each meal. The physician ordered 6 small meals instead of 3 larger ones. The care plan noted the resident refused the snacks stating the snacks would ruin their next meal. The Care Plan included the following interventions: a. Record weight every week-report changes of plus or minus 5 percent to Registered Nurse/Physician/Dietician. b. Serve regular diet and 6 small meals or snacks throughout the day. c. Give 180 milliliters health shake at each meal, give the shakes alone with no other drinks to increase intake. The resident does better with juice based drinks. d. Offer drinks, juice, tea, coffee, milk for snack between meals. The physician's orders [REDACTED]. a. A regular diet of 6 small meals per day, with a start date of 9/09/2010. b. Health shake or cranapple juice by mouth 3 times a day with meals. c. Weekly weight. The Nutritional assessment dated [DATE] identified the resident's weight at 96 pounds with a health shake offered at all meals/encourage fluid between meals. The assessment identified the resident had no chewing swallowing concerns and his/her food intake between 25-50%. The assessment identified the resident able to feed him/her(self) with set up assistances. The assessment identified the resident mental status as forgetful/confused and his/her skin integrity as fragile. Record review of the resident's Nutritional Progress Notes written by the contracted Dietician documented the following: a. On 7/12/12 the resident's weight declined to 96 pounds. The resident's weight is down 2 1/2 pounds, continue to stress offering fluids between meals and continue the Health Shakes at all meals. There were no other interventions noted. The Resident Weight Tracking System Report the resident's weight on 10/07/12 at 90.70 pounds. The Nutritional assessment dated [DATE] identified the resident's weight at 90.7 pounds. The assessment identified a weight loss of 5.3 pound from the last assessment (7/12/12) and calculated a 5.5 % loss (significant loss). The assessment identified the resident's intake averaged at 40%, with lower fluid intake (600 cc). Record review of the resident's Nutritional Progress Notes written by the contracted Dietician documented the following: b. On 10/10/12, the resident's weight down to 90.7 pounds. (The resident's significant unplanned weight loss of greater than 5% percent was not identified as such.) The dietician recommended offer and encourage between meals fluids, offer 3 times a day snacks, Health Shakes at every meal, and offer and encourage small frequent meals and snacks to prevent weight loss. A facsimile (fax) to the physician dated 11/18/12 requested to discontinue the small 6 meals a day due to the resident's non-compliance. The physician's response directed staff to try 6 meals a day again. Record review of the Nurse's (Interdisciplinary Notes) notes failed to document any identification of a significant weight loss except on 12/10/12. There is was noted the resident's weight was down 3 pounds, poor appetite at all meals, receives medpass (a supplement) with medication pass, and has health shakes at meals but often refuses. The Resident Weight Tracking System Report a weekly weight on 12/30/12 weight of 89.30 pounds The Nutritional assessment dated [DATE] identified the resident's weight at 89.3 pounds. The assessment identified a weight loss of 1.4 pounds or calculated a 1% loss. Record review of the resident's Nutritional Progress Notes written by the contracted Dietician documented the following: c. On 1/03/13, the resident's weight down to 89.3 pounds. The progress note identified the resident's intake had decreased and recommended to continue to offer snacks and fluids between meals and small frequent feedings. The progress note documented to discontinue a protein supplement, Arginidate ( this supplement had not been documented before). The progress note identified the resident's skin integrity was intact and the resident did not drink the protein supplement. There were no other suggestions to attempt. The Resident Weight Tracking System Report weekly weight of 85 pounds on 2/24/13. Observation during survey on 3/04/13 through 3/06/13 noted staff sitting with the resident, assisting or cueing for meals, with varied intake, poor appetite and little interest noted. Strawberry Health shakes was served at every meal, which the resident would drink 25 to 50 percent typically. The health shake was observed served alone 1 out of 5 times (4 of 5 times the health shake had been served with other drinks). Observation on 03/04/13 from 12:53 p.m. through 6:05 p.m. revealed the resident sitting in the chair in the television room without any change in position by staff, without any offers of fluids, without any offers to be taken to the bathroom or incontinence care provided. For 5 hours the resident was unattended by staff. (The resident was removed from the noon meal in the dining room to the television room (per resident request), sat and dozed on and off and then ambulated with assistance back to the dining room for the evening meal.) Observation on 03/06/13 at 7:30 a.m., revealed the resident finger eating toast with butter and jelly and doing a fair intake (no staff was present). The physician notes dated 11/28/12 and 1/23/13 failed to identify the resident with significant weight loss. During an interview on 03/05/13 at 1:00 p.m., Staff C, Licensed Practical Nurse, stated the resident does not receive 6 small meals per day as he/she continuously refused. Staff C reported the resident stated this ruins his/her appetite for the meals. Staff C did note the resident was on [MEDICATION NAME] but also refused that so it was discontinued. 2. The MDS for Resident #1 dated 2/7/13, documented [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of one with eating. The care plan dated 1/8/13, included a problem of impaired nutrition. The problem included no intervention to notify the physician of weight changes. A review of the resident weight tracking system report from 9/2/12 to 3/3/13, revealed the following weight changes: a. On 9/16/12 weight at 155 pounds. b. On 12/29/12 weight at 145pounds. c. On 3/3/13, weight at 141 pounds. A review of the clinical record revealed no physician notification of the above significant weight changes. 3. The MDS for Resident #2 dated 1/29/13, documented [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of one with eating. The care plan dated 2/1/13, included a problem of impaired nutrition. The problem included an intervention to record weight every week and report changes of +/- 5% to RN/MD/RD as tolerated. A review of the resident weight tracking system report from 9/2/12 to 3/3/13, revealed the following weight changes: a. On 9/2/12 weight at 194 pounds, 15.38% 6 months b. No December weight c. On 2/3/13, -5.48% 1 month weight at 198.8 pounds d On 3/3/13, -8.83% 3 months, weight at 188 pounds A review of the clinical record revealed no physician notification of the above weight changes. The facility Director of Nursing stated on 3/6/13 at 3:30 p.m., that physician notification of weight changes would be a nursing responsibility. The DON stated he/she had not been aware of this being done. 4. The admission Profile Face Sheet undated identified Resident #9 with [DIAGNOSES REDACTED]. The Minimum Data Set(MDS)assessment tool dated 02/27/13 identified the resident with short and long term memory loss indicating severe impairment with making daily decisions and required extensive assistance of 1 to 2 staff persons for all cares, with limited assistance with eating. The MDS noted the resident's weight at 78 pounds and noted a weight loss of 5 percent or more in the last month or a loss of 10 percent in the last 6 months. The Care Plan for the resident dated 02/28/13 identified an impaired nutrition and has declined significantly (is on Hospice care), has difficulty feeding self, but resists assistance from staff. The resident only eats bites and sips at most meals. The Care Plan included the following interventions: a. Record weight every week-report changes of plus or minus 5 percent to Registered Nurse/Physician/Dietician. b. Provide a supplement drink at snack time. c. Offer a snack at about 11:00 a.m. for example cheese and crackers and a health shake. d. Serve a health shake with all meals. d. Offer drinks, juice, tea, coffee, milk for snack between meals. The Resident Weight Tracking System Report noted the following: a. 9/30/12: weight of 80 pounds b. 11/25/12: weight of 82.5 pounds c. 2/24/13: weight of 77.5 pounds. Observation on 03/05/13 at 10:45 a.m. through 11:11 a.m., revealed the resident in bed. There was no health shake or snack offered to the resident as noted in the resident's care plan. Record review of the Nurse's (Interdisciplinary Notes)notes failed to document any identification of a significant weight loss, failed to document any calls or fax's to the physician for the dates noted for weight changes. During an interview on 03/05/13 at 8:58 a.m., Staff A, Registered Nurse, stated the resident was on Hospice cares, so the weight loss was expected and did not think there had to be any notifications. Staff A was unsure who was responsible to notify the resident's physician regarding the significant weight loss. The resident's spouse visits daily and is aware of the weight loss status, as it has been an ongoing process. Staff A also commented that any resident who does not eat well at mealtime would receive medpass (a supplement) when passing out the resident's medications, but probably was not recorded. During an interview on 03/05/13 at 10:43 p.m., the Director of Nursing stated it was the Nursing department's responsibility to make the notifications for significant weight loss. During an interview on 03/05/13 at 11:46 a.m., Staff B, Direct Care Worker(Certified Nursing Aide)stated they did not give the 11:00 a.m. snack, as they were busy assisting at Bingo. The kitchen is responsible for bringing out the snack to be offered. Staff B also commented the snack doesn't always happen, especially if they are busy.