Every finding on record at Glen Haven Health and Rehabilitation, LLC

Based on interviews and record reviews, the facility failed to check the pacemaker function as ordered for discharged Resident #428, Resident #11, and Resident #93, three of seven sampled residents identified by the facility as having a pacemaker. Resident #428 had a physician's order to check the function of their pacemaker (a small electronic device, implanted in the chest to regulate the heart's rhythm) every month. The facility did not have evidence to indicate the resident's pacemaker was checked monthly as ordered by the physician from April of 2021 until after discharge on [DATE]. On [DATE], Resident #428 was found unresponsive, pale in color, with a heart rate of 38 beats per minutes (a normal resting heart rate range for adults range from 60 to 100 beats per minute). The resident was transferred to the local hospital for further evaluation. At the hospital, Resident #428 was profoundly bradycardic (heart rate slower than 60 beats per minute) and his/her pacemaker not functioning properly. Resident #11 and Resident #93 also had physician's orders to check the function of their pacemaker. Interviews with facility staff revealed these resident's pacemaker was not checked as ordered by the physician. It was determined the facility's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of K. On [DATE] at 1:00 PM, the Administrator, Regional Administrator, Regional Nurse Consultant, and the Director of Nursing (DON) were provided the IJ template and notified of the findings at substandard quality of care at the immediate jeopardy level in the area of Quality of Care at F684-Quality of Care. The IJ began on [DATE] and continued until [DATE] when survey team verified onsite that corrective actions had been implemented. On [DATE] the immediate jeopardy was removed, F684 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. Findings included: Cross Reference F867 QAPI/QAA Improvement Activities and F726 Competent Nursing Staff. 1. A review of Resident #428's Face Sheet revealed the facility admitted the resident on [DATE]. Resident #428 had diagnoses that included Atrial Fibrillation (an abnormal rhythm of the heart) and Presence of a Cardiac Pacemaker. Resident #428 was discharged on [DATE]. A review of Resident #428's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of four, which indicated Resident #428 had severe cognitive impairment. A review of Resident #428's Care Plan(s), with a review date of [DATE], indicated the resident had a potential for alteration in their cardiac function related to a pacemaker. The goal was for no complications related to the pacemaker as evidenced by a heart rate within normal limits. Interventions directed staff to check the pacemaker per schedule. A review of Resident #428's Physician Orders, for [DATE], indicated an order dated [DATE] to check the resident's pacemaker every month. A review of Resident #428's Departmental Notes, dated [DATE] - [DATE], revealed no evidence the resident's pacemaker was checked. A review of Resident #428's Departmental Notes, dated [DATE] at 2:39 PM, indicated the resident was found sitting on the side of their bed with their eyes closed and breathing through his/her mouth. The resident did not respond to sternal (chest) rub, was pale in color and had a heart rate of 38 beats per minute (normal range is 60 beats to 100 beats per minute). Per the note, the resident was transferred to the hospital for further evaluation. A review of the hospital Emergency Department Note, dated [DATE], indicated Resident #428's chief complaint as arrhythmia (abnormal heart rhythm)/palpitations (the perceived abnormality of the heartbeat characterized by hard, fast, or irregular beats). Per the note, the resident's heart rate was 37 bpm. The Medical Decision Making (MDM) indicated, Resident #428 arrived at the hospital profoundly bradycardic. The MDM further specified, a doctor evaluated the resident and found the resident's pacemaker did not function properly. A telephone interview was held with a family member (FM) of Resident #428 on [DATE] at while a resident of the facility. The FM stated on [DATE], the facility called and informed them Resident #428 had been found unconscious and would be sent to the hospital. The FM said when they arrived at the hospital, the resident's heart rate was 30 beats per minute and the resident immediately received a new pacemaker due to one of the pacemaker's leads not functioning. The FM stated the resident expired about a week after she was hospitalized and during that time developed blood clots in her legs and lungs. In an interview on [DATE] at 8:10 AM, Registered Nurse (RN) #15/Unit Manager, stated a resident's pacemaker was ordered by the physician to be checked either once a month or every three months. RN #15 stated checking a resident's pacemaker was the responsibility of the assigned nurse or the unit manager. RN #15 stated she expected the resident's pacemaker check to be recorded in the nurse's note. RN #15 reviewed the orders for Resident #428 and stated since the resident's order had a specific date of the 8th of the month and a time, the order should have been transferred to the MAR for the 8th of every month on the ,d+[DATE] shift. RN #15 reviewed Resident #428's Medication Administration Record (MAR) and the nurse's (departmental) notes for [DATE], [DATE], and [DATE] and stated she was unable to find any information that indicated the resident's pacemaker had been checked. Licensed Practical Nurse (LPN) #14 was interviewed on [DATE] at 10:17 AM. She stated she worked with Resident #428 as the resident's primary nurse at least five days a week for six years. LPN #14 stated she did not check Resident #428's pacemaker function. In an interview on [DATE] at 1:20 PM the Director of Nursing (DON) stated she was unable to find any information in Resident #428's medical record to support the facility completed pacemaker checks for the resident. A telephone interview was conducted on [DATE] at 4:30 PM with the Device RN from Resident #428's cardiologist office. The RN stated he expected all physician orders to check pacemakers to be followed. He stated it was not acceptable for the facility to not check Resident #428's pacemaker after the last cardiology visit in April of 2021 and until the [DATE] hospitalization . The RN stated a pacemaker malfunction could be detected during a pacemaker check. The Device RN also stated, any traumatic event or fall could damage or break a pacemaker wire and result in an immediate problem with the pacemaker. He stated there were no documented falls for Resident #428, so one would believe the wires on the resident's pacemaker were worn. The RN stated a resident could maintain a normal pulse range and still have a worn pacemaker lead or a malfunctioning pacemaker. Per the RN, it was possible if Resident #428 had regular pacemaker checks the malfunction could have been detected and Resident #428's emergent pacemaker replacement and accompanying problems could have been avoided. In a follow-up interview on [DATE] at 8:00 AM, the DON stated the facility did not have a policy on pacemakers. The DON reported she was not aware the resident's pacemaker was not checked as ordered. The DON explained she could not answer why the resident's pacemaker was not checked as ordered and care planned. Per the DON, the last time the resident's pacemaker was checked was in [DATE], when the resident's family took to resident to see the cardiologist (a doctor who specialized in treating diseases of the cardiovascular system, mainly the heart and blood vessels). In another interview on [DATE] at 9:20 AM, the DON stated she expected staff to follow through on all physician's orders. The DON stated was unable to recall any details about Resident #428's transfer to the hospital on [DATE]. The Administrator was interviewed on [DATE] at 9:59 AM, the Administrator stated she expected physician's orders to be followed. During an interview on [DATE] at 10:36 AM, Resident #428's primary physician stated he expected physician's orders to be followed. 2. A review of Resident #11's Face Sheet indicated the facility admitted the resident on [DATE] with diagnoses that included Thoracic Aortic Aneurysm, Chronic Systolic (Congestive) Heart Failure, Hypertensive Heart Disease, and a Cardiac Pacemaker. A review of Resident #11's quarterly MDS, with an ARD of [DATE], indicated Resident #11 had a Brief Interview for Mental Status BIMS score of 14, which indicated the resident was cognitively intact. A review of Resident #11's Care Plan (s) with a start date of [DATE] and a review date of [DATE], indicated the resident had an alteration in cardiac function related to a pacemaker. Interventions directed staff to check the pacemaker per schedule. A review of Resident #11's Physician Orders, for [DATE], indicated an order dated [DATE] to check the resident's pacemaker every three months in June, September, December, and March. During an interview on [DATE] at 9:13 AM, Resident #11 stated it had been a while since their pacemaker was checked. RN #15/Unit Manager stated she was unsure when the resident's pacemaker was checked. 3. A review of Resident #93's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses of Vascular Dementia and Encounter for Checking and Testing of Cardiac Pacemaker Pulse Generator. A review of Resident #93's quarterly MDS, with an ARD of [DATE], revealed Resident #93 had a BIMS score of three, which indicated the resident had severe cognitive impairment. A review of Resident #93's Care Plan(s), with a start date of [DATE], revealed the resident had potential for alteration in cardiac function related to a pacemaker. Care plan interventions directed the staff to the resident's pacemaker per schedule. A review of Resident #93's Physician Orders, for [DATE] revealed an order dated [DATE] to check the resident's pacemaker every month. A review of Resident #93's Departmental Notes, from [DATE] to [DATE] revealed no evidence of documentation denoting the resident's pacemaker was checked. During an interview on [DATE] at 7:37 AM, LPN #8 revealed when Resident #93 was admitted to the facility in [DATE] the resident did not have a cardiologist and Resident #93 had not had a cardiologist since admission. LPN #8 further revealed she had never checked the pacemaker and thought the Registered Nurses checked the pacemaker but could not find any documentation the pacemaker had ever been checked. During an interview on [DATE] at 4:31 PM, Licensed Practical Nurse LPN #2 revealed she knew Resident #93 had a pacemaker, but she had never checked the function of the resident's pacemaker. In an interview on [DATE] at 2:48 PM, LPN #7, Unit Manager, stated she was not aware Resident #93 had a pacemaker. LPN #7 continued to say that there was not a task to check the pacemaker on the resident's MAR so she would not know to check it. During an interview on [DATE] at 4:35 PM, RN #3 stated she had never checked the function of a resident's pacemaker. On [DATE] at 2:50 pm a follow-up interview was conducted with LPN #14, Unit Coordinator. LPN #14 said the facility did not have a way to check residents' pacemakers. LPN #14 stated the only way staff would know that the resident needed a pacemaker check was if the cardiologist had called to schedule the check. During an interview on [DATE] at 2:55 PM, the Assistant Director of Nursing (ADON) stated she never noticed the resident's pacemaker was not checked every month. The ADON said she did not know why the order for a pacemaker to be checked every month did not come up on the MAR as a task. The nurses on the floor could not see the order and did not know to check the pacemaker monthly. The ADON said there was an issue with the pacemaker checks orders not being added to the MAR. In a follow-up interview on [DATE] at 9:11 AM, the DON stated the facility had quarterly care plan meetings in which staff reviewed the resident's physician's orders and care plan. Per the DON, in these meetings, nursing staff should have identified the physician's orders were not being completed. In an interview on [DATE] at 10:10 AM, the Administrator revealed the electronic MAR was not showing the physician's order to check the pacemaker monthly. The Administrator stated quarterly meetings are held with staff from all disciplines and during the meeting monthly orders should be checked to assure the orders were being implemented. The Administrator said staff missed that the pacemaker was not being checked and acknowledged the facility missed the fact Resident #93's pacemaker was not checked monthly. ********************************************** On [DATE] the facility submitted the following acceptable Removal Plan: 1. Registered Nurse Unit Managers, Director of Nursing and/or Assistant Director of Nursing notified the cardiologist/physician for the [three] residents identified to verify orders for monitoring of pacemaker checks and specific equipment needed. Registered Nurse Unit Managers initiated contact with three equipment companies on [DATE] to obtain pacemaker monitoring device. The necessary equipment has been ordered for eight residents whose pacemakers cannot be checked remotely. If the equipment does not arrive, Registered Nurse Unit Manager or Director of Nursing or Assistant Director of Nursing/Designee, will contact the specific pacemaker device company to complete an onsite pacemaker check. All pacemakers were checked between [DATE] - [DATE]. All were found to be in good working order. The physician indicated to check the resident's pacemaker function again, monthly, or quarterly, as indicated per physician orders based on the residents' specific needs. 2. To ensure all pacemakers were checked as ordered while awaiting the ordered equipment, the Administrator contacted a Medtronic pacemaker representative via phone on [DATE], and the representative made a facility visit to check pacemakers for 10 residents whose pacemakers cannot be checked remotely on [DATE]. The remaining three residents had their pacemakers checked onsite, with the results sent to the facility on [DATE]. The Administrator verified all residents with pacemakers had their devices checked, either onsite or remotely, on [DATE]. No concerns were identified with the pacemakers or the residents during the checks. 3. Registered Nurse Unit Managers reviewed the medical record and identified nine additional residents within the facility with pacemakers, for a total of 13 current residents with pacemakers. This review was completed by the Registered Nurse Unit Managers on [DATE]. 4. The facility has developed and implemented, on [DATE], a pacemaker policy related to the checking of pacemakers and documenting the pacemaker checks on the resident's medication administration record to ensure pacemakers are monitored at prescribed frequency. 5. Licensed nurses will be responsible for completion of the pacemaker checks per the care plan, documenting the pacemaker checks on the medication administration record per the care plan and the Registered Nurse Unit Manager or Director of Nursing or Assistant Director of Nursing/Designee will verify the checks have been completed. 6. The Director of Nursing, Assistant Director of Nursing, and Registered Nurse Unit Managers will be educated on [DATE] by the Regional Nurse Consultant/designee regarding following physician orders related to monitoring of pacemaker checks and obtaining necessary equipment when needed. 7. All licensed staff, to include contract nurses, will be educated by the Director of Nursing/designee regarding following physician orders related to monitoring of pacemaker checks and necessary equipment needed. This education will be initiated on [DATE]. This education will be provided to staff prior to their next scheduled shift. In addition, education will be added to new licensed staff orientation. As of [DATE] at 5:00 PM, 14 of 21 LPNs and 12 of 16 RNs have received the education. Licensed nurses working the night shift and weekends will be educated by the Director of Nursing or Assistant Director of Nursing or Registered Nurse Unit Managers/Designee prior to their next shift. 8. New admissions/readmissions will be reviewed daily, seven days a week by the Registered Nurse Unit Manager or Director of Nursing or Assistant Director of Nursing/Designee, to ensure Physician orders are initiated for residents with pacemakers to include how to perform specific device pacemaker checks and ensure necessary equipment is available. After review, any resident admitted with pacemaker will have orders obtained for monitoring and needed equipment. 9. Based on the actions listed above the completion date of this plan is [DATE]. The immediacy of the IJ was removed on [DATE]. ******************** On [DATE], after reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F684 was lowered to E, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. 18381

Based on interviews, record review, and review of the facility policy, the facility's Quality Assurance Performance Improvement (QAPI) committee failed to thoroughly review all factors related to Resident #428 emergent discharge to the hospital on [DATE]. The facility QAPI committee further failed to develop and implement corrective action. Resident #428 had a physician's order to check the function of their pacemaker (a small electronic device, usually placed in the chest to help regulate slow electrical problems with the heart) every month. The facility did not have evidence to indicate the resident's pacemaker was checked as ordered by the physician after [DATE]. On [DATE], Resident #428 was found unresponsive, pale in color, with a heart rate of 38 beats per minutes (a normal resting heart rate range for adults range from 60 to 100 beats per minute). The resident was transferred to the local hospital for further evaluation and found the resident's pacemaker did not function properly. Following Resident #428's emergent discharge QAPI committee failed to identify his/her pacemaker had not been checked as ordered. Resident #11 and Resident #93 were found to have a pacemaker, orders to check the pacemakers, and no evidence the pacemakers were being checked as ordered. This failure to investigate and implement corrective actions to ensure resident's pacemakers were checked as ordered had the potential to affect the remaining six sampled residents who had a pacemaker and currently resided in the facility. It was determined the facility's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to residents. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, 483.75 (Quality Assurance and Performance Improvement) at a scope and severity of K. On [DATE] at 1:00 PM, the Administrator, Regional Administrator, Regional Nurse Consultant, and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) situation. On [DATE] at 1:00 PM, the Administrator, Regional Administrator, Regional Nurse Consultant, and the Director of Nursing (DON) were provided the IJ template and notified of the findings at the immediate jeopardy level in the area of Quality Assurance and Performance Improvement at F867-QAPI/QAA Improvement Activities. The IJ began on [DATE] and continued until [DATE] when the survey team verified onsite that corrective actions had been implemented. On [DATE] the immediate jeopardy was removed, F867 remained at the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. Findings included: Cross Reference F684 Quality of Care and F726 Competent Nursing Staff. Review of a facility policy titled, Quality Assurance/Quality Assurance Performance Improvement, effected [DATE], indicated Policy: Our purpose is to provide excellent quality resident/guest services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the resident/guest cost effectively while maintaining good resident/guest outcomes and perceptions of resident/guest care . The policy specified, .QAPI Plan address: a. Clinical Care - Monitor existing QM [quality measures] results, [corporation name] infonet monitors for . incident reports, infection reports, discharges . Per the policy, .Administration is responsible and accountable for developing, leading and closely monitoring of QAPI program . A review of Resident #428's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses that included Atrial Fibrillation and Presence of a Cardiac Pacemaker. Resident #428 was discharged on [DATE]. A review of Resident #428's Care Plan(s), with a review date of [DATE], revealed interventions that directed staff to check the pacemaker per schedule. A review of Resident #428's Physician Orders, revealed an order dated [DATE] to check the resident's pacemaker every month. A review of Resident #428's Departmental Notes, dated [DATE] - [DATE], revealed no evidence of documentation denoting the resident's pacemaker was checked. A review of Resident #428's Departmental Notes, dated [DATE] at 2:39 PM, indicated Resident #428 was unresponsive and had a heart rate of 38 beats per minute (normal range is 60 beats to 100 beats per minute). Per the note, the resident was transferred to the hospital for further evaluation. A review of the hospital Emergency Department Note, dated [DATE], indicated Resident #428's had a heart rate of 37. The Medical Decision Making (MDM) indicated; Resident #428 arrived at the hospital profoundly bradycardic. The MDM further specified, a doctor evaluated the resident and found the resident's pacemaker did not function properly. A review of Resident #428's Departmental Notes, dated [DATE] 12:03 AM, indicated Registered Nurse (RN) #52 received an update from the hospital the hospital regarding Resident #428's condition and was notified the resident had a diagnosis to include pacemaker lead failure. Per the note, the hospital staff notified the RN, Resident #428 had received a new pacemaker. A telephone interview was held with a family member (FM) of Resident #428 on [DATE] at 9:20 AM. The FM stated the entire time Resident #428 lived in the facility, they had no knowledge of the resident's pacemaker was checked. The FM stated the resident expired about a week after she was hospitalized and during that time developed blood clots in her legs and lungs. During an interview on [DATE] at 2:55 PM, the Assistant Director of Nursing (ADON) stated she never noticed the resident's pacemaker was not checked every month. The ADON said she did not know why the order for a pacemaker to be checked every month did not come up on the MAR (Medication Administration Record) as a task. The nurses on the floor could not see the order and did not know to check the pacemaker monthly. The ADON said there was an issue with the pacemaker checks orders not being added to the MAR. In an interview on [DATE] at 1:20 PM the Director of Nursing (DON) stated she was unable to find any information in Resident #428's medical record to support the facility completed pacemaker checks for the resident. A telephone interview was conducted on [DATE] at 4:30 PM with the Device RN from Resident #428's cardiologist office. Per the RN, it was possible if Resident #428 had regular pacemaker checks the malfunction could have been detected and Resident #428's emergent pacemaker replacement and accompanying problems could have been avoided. In an interview on [DATE] at 8:00 AM, the DON reported she was not aware the resident's pacemaker was not checked as ordered. The DON explained she could not answer why the resident's pacemaker was not checked as ordered and care planned. Per the DON, the last time the resident's pacemaker was checked was in [DATE], when the resident's family took to resident to see the cardiologist (a doctor who specialized in treating diseases of the cardiovascular system, mainly the heart and blood vessels). The DON reported the facility did not have a policy on pacemakers. In a follow-up interview on [DATE] at 2:57 PM, the Administrator stated residents who were discharged /transferred were discussed in the facility's morning meetings to determine the reason for discharge/transfer. She stated the QAPI committee discussed specifics about each resident discharge/transfer. The Administrator indicated she was not the administrator at the time and the DON might have the QAPI review of Resident #428's transfer to the hospital. On [DATE] at 3:18 PM, the DON stated Resident #428's discharge was reviewed, but she was unable to recall anything that was discussed about the resident's discharge. The DON stated residents' discharges were reviewed each Monday, and the information discussed included an attempt to determine if the resident's discharge could have been prevented. The DON stated they tried to determine root cause and if the transfer could have prevented. The DON stated there were no changes implemented as a result of Resident #428's emergent transfer to the hospital. On [DATE] at 4:02 PM, the Administrator stated pacemakers were not discussed in the facility's QAPI meetings. ************************************************************************************************************************************************************************************************ On [DATE] at 10:22 AM, a Removal Plan was submitted by the facility and accepted by the state survey agency. The Removal Plan read as follows: 1. Those likely to suffer are the facility residents with the potential for any adverse reaction due to the failure to meet, discuss, and institute the collection of data and monitoring of other residents and processes. An emergency Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE] to address failure to meet, discuss, and institute collection of data and monitoring of other residents and processes related to an adverse event involving Resident #428 and failure to have a policy in place or defined process for pacemakers or checking pacemakers. It was determined that the root cause related to no pacemaker policy. The policy was developed and implemented on [DATE]. Those in attendance included the Regional Administrator, Regional Nurse Consultant, Regional Quality Assurance Nurse, Administrator, Director of Nursing, and Medical Director. 2. The Quality Assurance Committee (Administrator, Director of Nursing, Assistant Director of Nursing, Medical Director, and Infection Control Preventionist) were reeducated on [DATE] by the Regional Director on policy and procedures of the QAPI meeting for consistent monitoring of QAPI programs to include Diagnostics, Event Reporting, Customer Relations, Policy and Procedure Review/Approval, Compliance/Regulatory, Rehospitalization , Other items Reviewed, Facility Assessment Results/Revisions/Annual Review, Action Plans, Survey Related Monitoring, Performance Improvement Project (PIP), and Emergency QAPI meeting minutes to ensure adverse events and quality deficiencies are identified, corrected, and monitored. 3. The Quality Assurance Committee (Administrator, Director of Nursing, Assistant Director of Nursing, Medical Director, and Infection Control Preventionist) will monthly review the QAPI program to ensure quality deficiencies and adverse events are corrected and monitored. Findings will be submitted monthly, for three months, to the Regional Administrator, Regional Nurse Consultant, and Regional Quality Assurance Nurse for review and revision. Any concerns identified will be immediately addressed and education will be provided. 4. Based on the actions listed above, the completion date of this plan is [DATE]. The immediacy of the IJ was removed on [DATE]. *************************** On [DATE], after reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F867 was lowered to E, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observations, interviews, and Food and Drug Administration (FDA) recommendations, the facility failed to ensure staff consistently wore hairnets in one of one facility kitchen areas where all resident food was prepared. The failure had the potential to affect all residents who received food items from the kitchen. The facility further failed to ensure staff did not handle ready-to-eat food with their bare hands. This affected one (Resident #118) of 34 sampled residents. Findings included: 1. Review of the 2022 FDA Food Code at FDA Food Code 2022: Full Document (01/18/2023 version) indicated, .2-402.11 Effectiveness. (A) Except as provided in [paragraph] (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean EQUIPMENT, UTENSILS . On 07/18/2023 at 10:27 AM, the Certified Dietary Manager (CDM) was observed walking through the kitchen without a hairnet. The CDM proceeded to walk through the kitchen again at 10:34 AM and 10:36 AM without a hairnet. There was an open bag of dried mashed potatoes and an open carton of liquid eggs on the counter and unopened boxes of food in areas where the CDM walked. During an interview on 07/20/2023 at 2:45 PM, the CDM acknowledged she was not wearing a hairnet during the 07/18/2023 observation and stated she should have been wearing a hairnet. On 07/21/2023 at 10:54 AM, Cook #49 was observed in the kitchen putting pudding into bowls while not wearing a hairnet. Cook #49 acknowledged he should be wearing a hairnet. During an interview on 07/20/2023 at 2:45 PM, the Registered Dietician (RD) stated a hairnet should always be worn in the kitchen. During an interview on 07/24/2023 at 9:11 AM, the Director of Nursing (DON) stated staff should always wear hairnets in the kitchen and indicated a hairnet should be worn throughout the kitchen. During an interview on 07/25/2023 at 9:27 AM, the Administrator stated staff should always wear a hairnet when in the kitchen. 22445 2. On 07/19/2023 at 12:20 PM, Certified Nursing Assistant (CNA) #24 was observed preparing the lunch meal for Resident #118. CNA #24 held Resident #118's sweet potato with her bare hands while she cut the sweet potato into smaller pieces for the resident to consume. CNA then unwrapped the resident's chicken salad sandwich with her bare hands. CNA #24 held the resident's chicken salad sandwich in her bare hands while she cut the sandwich in half. CNA #24 confirmed she had touched Resident #118's sweet potato and chicken salad sandwich with her bare hands. CNA #24 was unable to give a reason she had not worn gloves when she touched Resident #118's food. In an interview on 07/19/2023 at 12:25 PM, Registered Nurse (RN) #15/Unit Manager stated the expectation was for staff to wear gloves when they touched a resident's food. The Director of Nursing (DON) was interviewed on 07/22/2023 at 11:19 AM and stated she expected staff not to touch resident's food with their bare hands due to infection control issues. During an interview on 07/24/2023 at 9:59 AM, the Administrator stated staff should not handle resident's food items with their bare hands.

Based on observations, interviews, record review, and facility policy review, the facility failed to provide timely nailcare for three (Residents #108, #152, and #146) of eight residents reviewed for activities of daily living (ADLs). Findings included: Review of a facility policy titled, Nail Care, dated 10/01/2010, indicated, .PURPOSE: Routine nail care helps reduce the potential for infection, prevents intrusion of the nail into the skin, prevents possible injuries and promotes a feeling of well-being for the resident. STANDARD: Nail care is a routine part of grooming each day. Foot care should be provided as a part of a tub or shower bath . Further review of the facility indicated, .It is recommended a Podiatrist provides foot care for residents with Diabetes or Peripheral Vascular Disease, and that a licensed nurse provide fingernail care for residents with those diagnoses . 1. A review of a Face Sheet indicated the facility admitted Resident #108 on 02/06/2020 and readmitted the resident on 05/19/2022 with diagnoses that included Dementia, Encephalopathy, Cerebral Infarction (stroke) with Left Sided Hemiplegia (weakness), Left Below the Knee Amputation (BKA), Right Above the Knee Amputation (AKA), and Type Two Diabetes Mellitus. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 06/28/2023, revealed Resident #108 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was totally dependent upon staff for dressing and personal hygiene. Review of Resident #108's Care Plan description, with a start date of 02/07/2020, revealed the resident required staff assistance with all ADLs related to decreased mobility, impaired cognition, impaired vision, left BKA, and right AKA. Interventions directed staff to assist with nail care. During observations on 07/18/2023 at 12:12 PM, 07/19/2023 at 1:20 PM, 07/20/2023 at 8:39 AM, 07/21/2023 at 9:15 AM, and 07/22/2023 at 10:46 AM, Resident #108's fingernails were long, extended past the fingertips, and curved back into the skin of the resident's fingers. Documentation of Resident #108's ADL care for July 2023 was requested from the facility on 07/25/2023 at 11:07 AM, and Registered Nurse (RN) #15 stated they did not have those documents available. During an interview on 07/22/2023 at 8:57 AM, RN #13 stated she was not sure how often nail care was supposed to be provided but thought it should be done as needed. During an interview on 07/22/2023 at 9:57 AM, Licensed Practical Nurse (LPN) #14 stated nail care should be provided when it needed to be done and the fingernails should not be allowed to get long enough that they were curving back into the skin of the fingers. During an interview on 07/22/2023 at 10:53 AM, Certified Nursing Assistant (CNA) #23 stated she had worked at the facility for [AGE] years. She stated nail care was to be provided on the evening shift at least once a week. She stated if a resident was diabetic a nurse should trim the nails. CNA #23 stated Resident #108's nails needed to be cut by the evening nurse since the resident was diabetic. She stated she told the day shift nurse that morning that Resident #108's nails needed to be trimmed so the nurse could pass it on to the evening nurse. During an interview on 07/22/2023 at 10:57 AM, after the Director of Nursing (DON) made an observation of Resident #108's fingernails, the DON stated the resident's nails were too long, needed to be trimmed, and she would make sure the nails were cut. She stated nail care should be provided as needed and the resident's nails should not have been allowed to get that long. She stated she was not able to say why the nail care was not provided. She stated it was the responsibility of the nurse on the hall where the resident resided to make sure nail care was performed. During an interview on 07/22/2023 at 3:21 PM, LPN #2 stated nail care should be provided as needed. She stated if the resident was diabetic, then the nurse would need to cut the nails; otherwise, a CNA should do it during the resident's bath. She stated any nurse could cut the resident's nails, and it was not assigned to a certain shift. She stated she was not aware Resident #108's nails needed to be cut. During an interview on 07/24/2023 at 9:09 AM, LPN #7 stated nail care was provided on Sundays on the evening shift by the CNAs unless the resident was diabetic, noting then the nurse was responsible. During an interview on 07/24/2023 at 9:24 AM, the DON stated nailcare should be provided as needed, and the CNAs should be checking the residents' nails during the bath. The DON said any staff member could provide nail care unless the resident was diabetic or on a blood thinner, and then a nurse should provide the nail care. The DON stated she did not know why Resident #108's nails were so long. During an interview on 07/24/2023 at 9:58 AM, the Administrator stated nail care should be provided when it was needed. She stated if the resident was diabetic, the nurse or podiatrist should provide the nail care. She stated RNs were responsible for ensuring nail care was provided. During an interview on 07/25/2023 at 9:27 AM, the Administrator reiterated that nail care should be provided as needed. She stated Resident #108's fingernails should have been cut before they got so long. She stated the staff would need to be reeducated to provide nail care when it was needed. 22445 2. A review of a Face Sheet for Resident #152 revealed the facility admitted the resident on 12/10/2021 with diagnoses that included Cellulitis of the Right Lower Limb, Dementia, and Adult Failure to Thrive. A review of a quarterly MDS, with an ARD of 06/07/2023, revealed Resident #152 had a BIMS score of 13, which indicated the resident had intact cognition. The MDS indicated Resident #152 required extensive assistance from staff for the completion of personal hygiene tasks. A review of Resident #152's Care Plan, with a start date of 12/10/2021, indicated the resident required assistance to complete ADLs. Interventions directed staff to provide assistance with nail care as needed. A review of Resident #152's Departmental Notes for the timeframe from 06/01/2023 through 07/19/2023 revealed no documentation of care refusals. An observation was made on 07/18/2023 at 10:51 AM of the great toenail on Resident #152's right foot. The toenail extended approximately an inch beyond the toe. Resident #152 stated during the observation that their toenails had not been cut in a long time and added the toenails on the left foot were so long they curved under the toe. An interview was held with Resident #152 on 07/20/2023 at 8:45 AM, and the resident stated their toenails had not been trimmed since admission to the facility. An observation was made of Resident #152's toenails on 07/20/2023 at 8:45 AM. The surveyor was accompanied by CNA #25. The CNA stated the resident's toenails were long and needed to be trimmed. The CNA validated the resident had a right great toenail that was approximately one inch in length, along with a left fourth toenail that was approximately one inch in length. Resident #152's other toenails, while long and curling, were not quite as long as the right great toenail and the fourth toenail of the left foot. CNA #25 stated the CNAs were responsible for cutting toenails, but today was her first day working with Resident #152. An interview was held with RN #15 on 07/20/2023 at 8:50 AM. RN #15 observed Resident #152's toenails and stated they needed to be clipped. RN #15 stated a podiatrist came to the facility, but the visits were sporadic. The RN stated that since Resident #152 did not have a diagnosis of diabetes, the staff could trim the resident's toenails and added she could give no reason why the toenails had not been trimmed. An interview was held with LPN #7 on 07/20/2023 at 11:55 AM. LPN #7 stated there were residents on her assignment who refused care, but she did not identify Resident #152 as a resident who refused care. LPN #7 stated it was the responsibility of the podiatrist to trim resident toenails. LPN #7 stated she had not seen Resident #152's toenails in a while. LPN #7 added she was not sure if the nurses were allowed to clip the resident's toenails and added no one had reported that Resident #152's nails needed to be trimmed. LPN #7 observed Resident #152's toenails at that time and stated she had no idea the resident's nails were so long. LPN #7 stated that, if she had known, she would have asked the DON if she could cut the resident's toenails. LPN #7 stated she expected the CNAs to report to her when resident nails needed to be trimmed. CNA #22 was interviewed on 07/21/2023 at 1:18 PM and stated she was the primary day shift nursing assistant for Resident #152. CNA #22 stated she had noticed that Resident #152's toenails were long and had reported the length of the toenails to LPN #7. The DON was interviewed on 07/20/2023 at 12:05 PM and stated she expected the CNAs to report any toenails that required cutting to the nurse and added if a resident did not have diabetes the CNAs were able to cut their toenails. She added the nurses were also able to cut toenails. The DON observed Resident #152's toenails at that time and stated she would not have expected staff to allow the resident's toenails to get that long before they were trimmed. 20958 3. A review of a Face Sheet revealed the facility admitted Resident #146 on 10/15/2021 with a diagnosis of Hemiplegia Following Cerebral Infraction Affecting the Right Dominant Side. The resident was receiving hospice care and services per the document. A significant change MDS, with an ARD of 06/23/2023, revealed Resident #146 had a BIMS score of seven, which indicated the resident had severely impaired cognition. The MDS indicated the resident required extensive assistance with dressing and personal hygiene tasks. Review of Resident #146's Care Plan, with a start date of 06/15/2023, revealed the resident required staff assistance with all ADLs due to impaired mobility. An intervention in the plan directed staff to provide nail care as needed. On 07/18/2023 at 10:10 AM, CNA #40 was observed providing a bed bath for Resident #146. The resident's toenails and fingernails were observed to be long and jagged, with a brown substance underneath the fingernails. The toenails on the resident's great toes were observed to be very thick; the toenails on the other four toes were long and curled around the tips of the toes. The CNA stated the resident's toenails and fingernails needed to be trimmed and the nurse would have to trim them. On 07/20/2023 at 10:25 AM, Resident #146 was observed receiving wound care from LPN #36. After the wound care was completed, LPN #36 stated the resident's fingernails and toenails were long and needed to be trimmed. LPN #36 said the resident was not seen by the podiatrist because the resident was receiving hospice services and stated she would have to talk to the Director of Nursing (DON) to see what could be done. On 07/20/2023 at 12:31 PM, CNA #41 was interviewed and stated the CNAs were responsible for the care of the residents' fingernails and toenails, unless a resident was a diabetic, noting then the nurses would provide the nail care. On 07/20/2023 at 12:34 PM, CNA #24 was interviewed. CNA #24 stated hospice staff had completed Resident #146's morning care and bed bath. CNA #24 observed the resident's fingernails and toenails and stated they needed to be cut and cleaned. CNA #24 reported hospice staff should have taken care of the resident's nail care that morning, but noted she would trim them. On 07/20/2023 at 12:40 PM, RN #1 was interviewed. The RN was asked about Resident #146's fingernails and toenails. She stated she had not inspected the resident's nails during skin assessments but now noted the nails needed to be cleaned and cut. During an interview on 07/22/2023 at 10:10 AM, LPN #14, a unit manager, stated a podiatrist came to the facility. LPN #14 said she did not think Resident #146 could have their toenails trimmed by the podiatrist because the resident was receiving hospice care. LPN #14 stated staff could tell the hospice nurse to provide nail care and hospice staff could trim the resident's fingernails, but not the toenails. During an observation on 07/23/2023 at 10:29 AM, Resident #146's toenails and fingernails remained long and jagged. During an interview on 07/23/2023 at 10:39 AM, the Assistant Director of Nursing (ADON) stated the podiatrist had visited the facility the previous day and trimmed some residents' toenails and was due to come back on 07/23/2023. The ADON reported Resident #146 had not received services due to being on hospice. The ADON said the facility staff usually provided nail care. On 07/23/2023 at 10:40 AM, LPN #14, unit manager, was interviewed and stated anyone who provided care for a resident should address the resident's nail care. On 07/24/2023 at 7:58 AM, the DON was interviewed. The DON stated Resident #146 was placed on a list for toenail trimming by the podiatrist. On 07/24/2023 at 8:00 AM, the Administrator stated her expectation was that a resident's nails would be trimmed as needed or the resident would see the podiatrist if needed.

Based on document review and interviews, the facility failed to train their nurses on how to perform a pacemaker check or have any documentation that a competency skill check was done to determine if nurses possessed the knowledge/skills to perform a pacemaker check. This failure had the potential to affect all 13 residents who resided in the facility identified as having a pacemaker. Findings included: Cross Reference F867 QAPI/QAA Improvement Activities and F684 Quality of Care. On 07/24/2023 at 10:26 AM, the Administrator presented the survey team with a list that indicated 13 residents, who resided in the facility, had a pacemaker (a small electronic device, usually placed in the chest to help regulate slow electrical problems with the heart). Resident #11 and Resident #93 both had a Physician Order to check their pacemaker and care planned intervention to check their pacemaker. A review of the Licensed Nurse Skills Competency Evaluation, revised 06/05/2018, did not indicate there was a skill check on how to perform a pacemaker check. Licensed Practical Nurse (LPN) #14 was interviewed on 07/22/2023 at 10:17 AM. She stated she had not received any training or validation of her competency skills to perform a pacemaker check since 2015. During an interview on 07/20/2023 at 4:31 PM, LPN #2 stated she had never received in-service on checking pacemakers. In an interview on 07/21/2023 at 2:48 PM, LPN #7, said there was never an in-service on how to check the pacemaker. During an interview on 07/20/2023 at 8:10 AM Registered Nurse (RN) #15/Unit Manager stated pacemakers were to be checked by physician's orders RN #15 stated checking pacemakers was the responsibility of the assigned nurse or the unit manager. In a follow-up interview on 07/21/2023 at 4:18 PM, RN #15 stated she only found out that week that she was responsible for checking the pacemakers. RN #15 said she had not received training on how to check the function of the pacemakers that were in use for the facility's residents. RN #15 stated she was aware how to check the function of a pacemaker from previous work experience, but no one at the facility had performed a competency skill check to ensure she checked a resident's pacemaker accurately. In an interview on 07/21/2023 at 8:00 AM, the Director of Nursing (DON) reported the facility did not have a policy on pacemakers. In an interview on 07/21/2023 at 3:18 PM, the DON the stated she did not remember the cardiac training provided to the nurses included how to check pacemakers. The DON reviewed the skills check list and confirmed there was nothing about pacemakers on the skills check list. The DON confirmed there were different types of checks for different types of pacemakers. The DON stated she expected the unit managers to make sure the pacemakers were checked as ordered. The DON stated RN #15 and RN #26, Unit Managers, had not been trained on the testing of the different types of pacemakers in the facility. During an interview on 07/21/2023 at 4:02 PM, the Administrator stated she expected the nurses who were responsible for checking pacemakers to be trained on the different types of pacemakers. The Administrator stated she had not seen anything about how to check a pacemaker on the skills checklist for the nurses.

Based on interviews, record review, and review of the facility's policy, the facility failed to ensure one (Resident #146) of two sampled residents reviewed for urinary catheter had a comprehensive care plan to direct staff how to care for the resident's suprapubic catheter. Findings included: Review of a facility policy titled, Person Centered Care Plans, with an effective date of 08/15/2018, indicated .Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest . The policy specified, .According to federal regulations, the facility develops a comprehensive person centered plan of care for each resident/guest that includes measurable objectives and timetables to meet a resident/guest(s) medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment . A review of Resident #146's Face Sheet revealed the facility admitted Resident #146 on 10/15/2021 with diagnoses that included Hemiplegia following Cerebral Infarction Affecting the Right Dominant Side and Urinary Retention. Review of the significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/23/2023, revealed Resident #146 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had an indwelling urinary catheter. Review of Resident #146's comprehensive care plan, revealed there was not a care plan that directed staff how to care for Resident #146's suprapubic catheter. During an interview on 07/21/2023 at 01:06 PM, the MDS Coordinator confirmed Resident #146's care plan did not address the care of the resident's suprapubic catheter. During an interview on 07/23/2023 at 8:13 AM, the Director of Nursing stated the care of the suprapubic catheter should be included in the resident's care plan. During an interview on 07/23/2023 at 8:20 AM, the Administrator stated the expectation was catheter care be care planned.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure urinary catheter tubing was secured in a manner to prevent trauma to the urethra for one (Resident #31) of four sampled residents reviewed for urinary catheter. Findings included: Review of a facility policy titled, Urinary Catheter Care, with an effective date of 11/10/2014, indicated, . Secure the catheter with a leg band or loop to the bed sheet in a comfortable position for the resident/guest . A review of Resident #31's Face Sheet indicated the facility admitted Resident #31 on 06/23/2023, with diagnoses that included Retention of Urine. Review of the admission Minimum Data Set (MDS), with an Assessment Review Date (ARD) of 06/29/2023, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS indicated the resident had an indwelling urinary catheter. Review of Resident #31's Care Plan(s), with a start date of 06/24/2023, indicated the resident had an indwelling urinary catheter related to a diagnosis of urinary retention. Interventions directed staff to use a leg strap to secure the resident's catheter tubing. During an observation on 07/25/2023 at 11:17 AM, Resident #31 was observed seated in a wheelchair with their urinary catheter collection bag positioned on the side. The resident's catheter tubing was not secured using a leg strap or another device. Certified Nursing Assistant (CNA) #18 confirmed the resident's catheter tubing was not secured. According to CNA #18, it was the nurses' responsibility to apply the leg strap that secured the resident's catheter tubing. During an interview on 07/23/2023 at 8:15 AM, the Director of Nursing stated it was her expectation that all indwelling urinary catheters and suprapubic catheter be secured with a leg strap or a stat lock.

Based on observations, interviews and the facility's policies titled Use of Gloves and Hairnets and Cleaning of Miscellaneous Equipment and Utensils, the facility failed to ensure: 1. staff wore hair nets covering all hair on the head Employee Identifier (EI#) EI# 4, EI# 5, EI# 6, and EI# 7 on 10/22/19 and 10/24/2019. 2. EI# 4 removed gloves and washed hands washing dirty in the dish room and then moving to the clean side of dishes in the dish room. 3. EI# 4 did not use four wet plates to place dinner meals on 10/23/2019. This deficient practice had potential to affect 184 out of 184 residents receiving meals from the kitchen and three out of sixteen residents receiving meals from one flat cart. Findings include: A review of the facility's policy titled, Use of Gloves and Hairnets, with an effective date of (MONTH) 15,2009, revealed . Process: .i. Wear hair restraints (bonnets, caps, nets) to cover hair when preparing or handling food. On 10/22/19 at 11:19 a.m., the Surveyor observed two Dietary Aids, Employee Identifier Number (EI# 4) (putting lunch meal on plates), Dietary Cook. EI# 6 (placing meals onto meal cart) wearing a hair net: The hair net was not covering either EI# 4 or EI# 6 hair completely. On 10/22/19 at 11:30 a.m., the Surveyor observed, EI# 7, Dietary Manager, entered the kitchen from the back door. EI# 7 was wearing a hair net on the top of EI# 7 head. The lower half of EI# 7 hair was not covered with a hair net. On 10/22/19 at 11:32 a.m., the Surveyor observed EI# 4, Dietary cook, entered the kitchen and walked to the area where other staff were putting meal trays onto cart with no hair net on. On 10/24/19 at 08:54 a.m., the Surveyor observed EI# 7 standing in the kitchen then after walking through the kitchen, and exited the kitchen door with hair net on. EI# 7's hair net, was covering the top portion of her hair however, the bottom portion of her hair was not covered. On 10/24/19 at 09:09 a.m., the Surveyor observed EI# 5's hair around faced exposed and not covered by the hair net. On 10/24/19 at 09:46 a.m., the Surveyor conducted an interview with EI# 5. EI# 5 was asked, what was the facility's policy regarding hair nets. EI# replied, everybody in the kitchen had to wear hair nets at all times. EI# 5 was asked, why. EI# 5 replied, for safety of the food so hair does not get in the food. EI# 5 was asked, what did hair nets cover, partial or all hair on staffs head. EI# 5 replied all the hair. EI# 5 was asked, was the hair net covering partial or all hair on her head. EI# 5 replied, partial hair was covered with a hair net. EI# 5 was asked, why was her hair net only covering partial of her hair. EI# 5 replied, because of the style of her hair. EI# 5 was asked, what was the potential harm to the resident with staff not wearing a hair net or partial hair not covered by a hair net in the kitchen. EI# 5 replied, the potential harm would be hair in the resident's food. On 10/24/19 at 10:01 am, the Surveyor conducted an interview with EI# 6. EI# 6 was asked, what was the facility policy regarding hair nets while working in the kitchen. EI# 6 replied, staff are supposed to make sure whole hair on the head was covered and guys wear beard restraints as well, while working in the kitchen. EI# 6 was asked, what was the harm with partial hair uncovered by the hair net while staff was working in the kitchen on 10/22/2019 and 10/24/2019. EI# 6 replied, some of the employee's hair could get in the residents food. EI# 6 was asked, what area in the kitchen were staff required to wear a hair net and completely cover an employees hair. EI# 6 replied, the whole kitchen including the raking area. On 10/24/19 at 02:23 p.m., the Surveyor interviewed EI# 3, Registered Dietitian. EI# 3 was asked, by her observation on 10/22/2019 was the dietary manager wearing a hair net that covered all of her hair covered while in the kitchen. EI# 3 replied, no. EI# 3 was asked, were hair nets available by the doors inside or outside of the kitchen on 10/22 and 10/23. EI# 3 replied, no. EI# 3 was asked, what staff were required to wear hair nets in the facility's kitchen. EI# 3 replied, any staff coming in and out of the kitchen. On 10/24/19 at 03:17 p.m., the Surveyor conducted an interview with EI# 7. EI# 7 was asked, where were the staff's hair nets stored prior to that day 10/24/2019 for staff use. EI# 7 replied, the hair nets were stored in the back of the kitchen on 10/22/19 and 10/23/19. EI# 7 was asked, why was the placement of the hair nets storage changed that day, 10/24/2019. EI# 7 replied, the storage of the hair nets were changed on 10/24/19 to ensure the facility's staff entering the kitchen wears a hair net. EI# 7 was asked, why should staff entering the kitchen wear a hair net. EI# 7 replied, the staff wore a hair net when entering the kitchen so hair would not fall into residents food or trays. EI# 7 was asked, should a hair net cover all or partial hair on the head. E# 7 replied, all of the staff's hair on the head, not partial should be covered with a hair net. 2. Review of the facility's policy titled, Use of Gloves and Hairnets, with an effective date of (MONTH) 15,2009, revealed: . Process: . c. Wash hands before and after wearing or changing gloves. e. Change gloves when activities are changed, . On 10/23/19 at 0615 p.m., the surveyor observed EI# 4, Dietary Cook, plating food for the residents meals. EI# 4 left the hot bar and walked into the dish room. EI# 4 rinsed four dirty plates and placed on a rack. EI# 4 ran the dish rack containing the plates through the dishwasher. EI# 4 removed the clean rack containing the four plates from the dishwasher. EI# 4 did not wash her hands between the process of moving from the dirty side to the clean side of the dish room. EI# 4 removed four plates from the dish rack on the clean side of the dish washer. On 10/24/19 at 12:03 pm, the Surveyor conducted a phone interview with EI #4. EI# 4 was asked, what did she do on 10/23/2019 when in the dish room in between moving from the dirty side to the clean side of the dish washer. EI# 4 replied, she removed her gloves but did not wash her hands or apply new gloves before unloading the clean plates from the dish washer. EI#4 was asked, why she did not wash hands or apply clean gloves when leaving the dirty side of the dish washer to the clean side. EI#4 replied, she was rushed for time and not paying attention. On 10/24/19 at 2:23 p.m., the Surveyor interviewed EI# 3. EI# 3 was asked, after a staff works on the dirty side of the dish washer and removes gloves what should be the next step the staff should take before going to the clean side of the dish washer. EI# 3 replied, the staff are supposed to wash the staffs hands. 3. A review of the facility's policy titled: Cleaning of Miscellaneous Equipment and Utensils, with an effective date of (MONTH) 3, 2019 revealed; .8. allow dishes to air dry . On 10/23/19 at 6:15 p.m., the Surveyor observed EI# 4, Dietary Cook, returned to the hot bar with four wet plates from the dishroom. EI# 4 plated meals on the four wet plates. There were water droplets observed on the plates. On 10/24/19 at 12:03 p.m., the Surveyor conducted a phone interview with EI #4. EI# 4 was asked, were the plates wet or dry that she returned to the hot bar with on 10/23/2019 for the dinner meal. EI# 4 replied wet. EI# 4 was asked, were the four wet plates used for the residents dinner meal on 10/23/2019. EI# 4 replied, yes the wet plates were used for dinner meals. EI# 4 was asked, what was the harm with her placing residents dinner meal on 10/23/19 on wet plates. EI# 4 replied, the wet plates could have remaining detergent on them. On 10/24/19 at 2:23 p.m., the Surveyor interviewed EI# 3. EI# 3 was asked, after washing and rinsing dirty dishes in the dish room with the dish washer what was the facility's staff next step regarding the clean plates. EI# 3 replied, the plates should be air dried. EI# 3 was asked, what should be the appearance of a plate before placing food items on the plates for the meals. EI# 3 replied, clean and dry. EI# 3 was asked, why should plates used for residents meals be clean and dry. EI# 3 replied, for appearance and safety. On 10/24/19 at 3:17 p.m., the Surveyor conducted an interview with EI# 7. EI# 7 was asked, what was the facility's policy regarding placing resident's food/ meal on a wet plate. EI#7 replied, the staff are not supposed to place food or meal on a wet plate. EI# 7 was asked, why should staff not place food on a wet plate. EI# 7 replied, to ensure no bacteria or any kind of growth.

Based on observation, interviews, and a facility policy titled, Medication Administration Procedures Eye Drops, the facility failed to ensure a licensed staff member did not place gloves, tissues, and eye drops in her pocket while administering eye drops to Resident Identifier (RI) #44. This had the potential to affect RI #44, one of two residents observed for the administration of eye drops. Findings include: A facility policy titled, Medication Administration Procedure Eye Drops, dated 03/11, revealed: . Procedures . 2. Obtain a clean barrier and place on over-bed table. 4. Remove the cap and place it on the barrier on the over-bed table. RI #44 was admitted to the facility on [DATE] and readmitted on [DATE]. On 10/24/19 at 8:05 a.m., an observation was made of Employee Identifier (EI) #2 Licensed Practical Nurse (LPN) during medication pass on RI #44. EI #2 placed gloves, tissues and eyedrops in her pocket. EI #2 gave the oral medications, went to wash her hands, removed gloves from her pocket and put them on. She then pulled the tissues and eye drops out of her pocket. EI #2 removed the top to the eye drops, placed the top in her pocket, administered the eye drops and handed the resident a tissue. She then removed the top to the eye drops from her pocket and placed it back on the eye drops and put them in her pocket and removed the gloves and washed her hands. On 10/24/19 at 11:27 a.m., an interview was conducted with EI #2. EI #2 was asked, how should she take eye drops into a resident's room. EI #2 replied, without the box, in her hand. EI #2 was asked, where did she put the eye drops, tissues, and gloves before she went into the resident's room. EI #2 replied, in her pocket. EI #2 was asked, what should be done with the cap of the eye drops when it was removed. EI #2 replied, she did not know. EI #2 was asked, what did she do with the cap of the eye drops when she removed it. EI #2 replied, she put it in her pocket. EI #2 was asked, should items be placed in her pockets. EI #2 replied, no. EI #2 was asked, what was the potential concern with placing the gloves, tissues, and eye drops in her pocket. EI #2 replied, contamination. On 10/24/19 at 12:39 p.m., an interview was conducted with EI #1 Registered Nurse (RN), Infection Control. EI #1 was asked, should a nurse place gloves, tissues, and eyedrops in her pocket when going to administer eye drops. EI #1 replied, no. EI #1 was asked, what should the nurse have done with the cap of the eye drops when it was removed. EI #1 replied put it on a clean barrier upward. EI #1 was asked, what was the potential concern of a nurse placing gloves, tissues, and eye drops in their pockets. EI #1 replied, contamination.

Based on observation, interview and the facility's policy titled Sanitation Principals , the facility failed to ensure one of three dumpster's doors were closed on 10/22/19. This affected one of three dumpster's observed. Findings include: A review of the facility's policy titled, Sanitation Principals, Effective Date: (MONTH) 10, (YEAR), that revealed, .d. dumpster's outside the nursing facility . should be kept covered when not actually being loaded. The area around the dumpster should be keep free of debris. On 10/22/19 at 11:49 a.m., the Surveyor observed with Employee Identifier (EI# 3) Registered Dietitian (RD), three dumpster's outside to the back of the facility. The middle dumpster had both doors opened. On 10/24/19 at 02:23 p.m., the Surveyor conducted an interview with EI #3. EI# 3 was asked, when the Surveyor and EI# 3 observed the dumpster's on 10/22/19, what did EI# 3 observe. EI# 3 replied, the dumpster doors were open. EI# 3 was asked, why did EI# 3 close the dumpster doors. EI# 3 replied, because the dumpster doors were not suppose to be left open because it was a potential for infestation of rodents or pest of any kind.

Based on observation, interviews, a review of regulations from the (YEAR) U.S. Food and Drug Administration Food Code, Thermometer Calibration (Food Republic), facility policies related to Therapeutic Supplements, Three Compartment Sink Sanitization, and Foods from Families and Friends, the facility failed to ensure: 1) cleaned cooking utensils were thoroughly air dried prior to stacking and storage; 2) commercially prepared, thawed milkshakes were consistently labeled with use-by dates for timely discard; 3) utensils and pans were sanitized when processed through the three-compartment sinks; 4) food thermometers used on the [DATE] tray line were accurately calibrated prior to use; 5) food brought into the facility from outside sources (family/friends) and stored in two of four nursing refrigerators was labeled with name and date to ensure timely discard; and 6) nursing staff maintained the interior of the refrigerators on each nursing station in a clean and sanitary condition for resident food storage. This had the potential to affect all (175) residents for whom meals were prepared and served at the time of this survey. Findings include: 1) AIR DRYING The (YEAR) Food and Drug Administration FOOD CODE mandates the following under ,[DATE].11 Equipment and Utensils, Air-Drying Required: After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining . a) On [DATE] at 1:35 PM, during the initial tour of the Dietary Department, the surveyor observed three of three steamtable pans (two ,[DATE] size and one ,[DATE]-size) stacked and stored wet-nested on storage racks in a storage room near the rear exit. b) On [DATE] at 10:05 AM, dishwashing staff were observed stacking clean ceramic plates prior to air-drying, as well as 4-ounce ceramic bowls onto a rolling cart in the dish room. At 10:15 AM, staff transferred the cart of stacked ceramic bowls to a slotted storage cart stored under the kitchen prep counter. No further drying was observed. A heavy plastic bag was then placed over the cart of stacked bowls, preventing further air-drying. Also, observed during dishwashing were plastic beverage glasses stored on flat trays after processing through the dish machine with drinking ends up, slightly wet. Additional flat trays filled with glasses were placed atop each tray, impeding further air-drying. c) At 11:10 AM, the Storage Room with the metal storage rack of stacked clean pans (adjacent to the back door) was again observed. Three of three steam table pans checked were stored wet-nested. On [DATE] at 5:05 PM, the Registered Dietitian, Employee Identifier (EI) #1 was questioned regarding the wet-nesting and above observations. EI #1 explained the lack of space in both the dish room and the kitchen hampered drying efforts. 2) USE-BY DATES The facility policy related to Therapeutic Supplements (Policy Number: DS. III-44), dated [DATE], cites the following thawing process to be used: .b. Shakes/supplements should be removed from the freezer, as needed, and placed in the refrigerator to thaw, at least one day ahead. Shakes/supplements should be labeled with the date removed from the freezer or with a used-by date which is 14 days from thaw date. Any product remaining after 14 days should be discarded. a) On [DATE] at 1:50 PM (during the initial tour) no use-by dates were visible on two of two thawed Ready Care milkshakes stored in the refrigerated milk box. Dated labels were likewise not consistently visible on all thawed milkshakes stored on nourishment trays in the walk-in refrigerator. b) On [DATE] at 10:15 AM, the surveyor again observed thawed milkshakes in the milk box, including one Ready Care Shake, and eight Mighty Shakes, all without use-by dated labels. On [DATE] at 10:35 AM, the surveyor asked EI #1 (the facility Dietitian) how the staff knew when to discard the commercially prepared milkshakes after thawed. EI #1 explained the staff have 14 days after the shakes are thawed. EI #1 further explained the staff were supposed to put a date on each container after thawed. 3) THREE-COMPARTMENT SINK SANITIZATION The facility policy titled: Three Compartment Sink Sanitization (Policy Number: DS. V-28), dated [DATE] outlines the process of sanitizing pots and pans in the third (sanitizing) sink as follows: Step One: Fill with hot water (at least 171 degrees Fahrenheit (F) or use chemical sanitizer (Quat (Quaternary) ammonia at 200 ppm (parts per million) Step Two: Immerse rinsed pots/utensils in sanitizer for at least one minute; or in hot water for at least thirty seconds Step Three: Allow pots/utensils to air dry; Store pots upside down or covered a) On [DATE] at 11:05 AM, the morning Cook (EI #2) processed pans through the 3-Compartment sinks. Despite the visibly dirty water in the first (wash) sink, EI #2 added more water and soap to the first sink and continued washing. The third (sanitizing) sink contained five serving scoops, submerged under the water. At the surveyor's request, EI #2 checked the temperature of the final rinse sink, and determined it was 90 degrees F. At this time (11:05 AM on [DATE]), the surveyor asked EI #2 what the final rinse water temperature was supposed to be. EI #2 responded, 165 to 170 degrees. (Minimum recommended=171 degrees). When asked if the temperature of 90 degrees F was OK, EI #2 indicated (nonverbally), yes. The surveyor asked EI #2 why a low water temperature was a problem. EI #2 did not answer. When asked who used the 3- compartment sinks, EI #2 responded it was the cook and the cook's helper. The surveyor then asked EI #2 when she had last changed the final rinse water. EI #2 stated they had changed the water after breakfast, about 1 and ,[DATE] hours ago. EI #2 then continued washing/processing utensils through the 3 compartment sinks, adding more hot water to the 3rd sink. Utensils including a wire whip, and slotted spoons were processed through the final rinse water despite the low final rinse temperature. On [DATE] at 11:10 AM, other utensils were observed draining by 3rd sink, including three full-size steam table pans, two plastic gallon pitchers, and a large (,[DATE] gallon capacity) aluminum strainer. b) At 12:00 PM (on [DATE]), the evening cooks had arrived into the kitchen and began preparing pans for the evening meal dessert. The surveyor asked one of the cooks, EI #4, to check the temperature of the 3rd (sanitizing) sink. EI #4 determined the water temperature was 100 degrees F, and pulled a frying pan and a 1 qt plastic pitcher from the final rinse sink, laying them on the drying rack. EI #4 stated the heating probe of the 3rd sink had been turned off. EI #4 immediately drained the water and refilled the sink. c) At 12:15 PM, the Cook's helper rinsed off a sheet pan in the first and second sinks and prepped the pan for use. The surveyor again asked EI #4 to check the final rinse water. EI #4 determined the final rinse water temperature was 143 degrees F. 4) FOOD THERMOMETER CALIBRATION The (YEAR) FOOD CODE specifies under ,[DATE].11 Good Repair and Calibration that .(B) FOOD TEMPERATURE MEASURING DEVICES shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. Directives for the Ice Water Method of food thermometer calibration (Food Republic, 2011) are as follows: 1. Fill a glass with ice cubes, then top off with cold water. 2. Stir the water and let sit for 3 minutes. 3. Stir again, then insert your thermometer into the glass, making sure not to touch the sides. 4. The temperature should read 32 degrees F. On [DATE] at 11:20 AM. the morning Cook (EI #3) checked several tray line food temperatures. The thermometer was placed between uses, in a cup of water with no ice and was observed to register 10 degrees F. At 11:20 AM, the surveyor asked EI #3 why she placed the thermometer into the ice-free water. EI #3 stated it was to make sure the thermometer was clean and calibrated. When asked what the temperature of the water was supposed to be (in order to calibrate), EI #3 responded 32 degrees F. EI #3 then removed the thermometer from the water (holding it in mid-air) and determined the reading to be 20 degrees F, at which time she began to adjust the dial head of the thermometer to 32 degrees without submersion into ice water). EI #3 told the surveyor she was not aware the thermometer should read 32 degrees in the ice water. On [DATE] at 5:05 PM, the Registered Dietitian, Employee Identifier (EI) #1 was alerted to the above observations. EI #1 provided verification of EI #3's thermometer calibration instruction ([DATE]). 5) NURSING STATION FOOD STORAGE, LABELING AND MONITORING The facility policy titled, Foods from Families and Friends (Policy Number: DS. II-20), dated [DATE] cited the purpose as: To preserve the resident/guest(s) right to receive gifts of food from family and friends, while reducing the potential for food borne illnesses. The process by which staff are to do this is listed as follows: a. Resident/Guest(s) are encouraged to consume foods that are brought to them from outside the facility as soon as possible. b. If food is to be stored, it should be labeled with resident/guest(s) name, dated and stored in airtight container. c. If refrigeration is necessary, food items should be stored in the nursing unit refrigerator or resident/guest(s) room refrigerator, and discarded after 72 hours. Station 1 On [DATE] at 9:22 AM, the surveyor and Licensed Practical Nurse (EI #5) observed the contents of the refrigerator in the utility room on Nursing Station 1. One bagged carry-out Styrofoam container of food, was stored inside the refrigerator, with no label (name or date). The surveyor then asked EI #5 who the container of food belonged to. EI #5 was not sure, due to the lack of a label. EI #5 confirmed the lack also of a date, thus preventing timely discard. Locked Dementia Unit On [DATE] at 5:03 PM, the Assistant Dietary Manager (EI #6) accompanied the surveyor to the refrigerator on Nursing Station 3. The following concerns were noted: a) one of three cartons of commercially-prepared milkshakes were stored without labels to indicate their use-by date; b) one 4-ounce container of yogurt was stored with an expired use-by date of [DATE] (confirmed by EI #6); c) one container of (2) slices of canned pineapple was stored with no date or name. When questioned, EI #6 stated the pineapple had been served at one of the meals on the previous day. d) One partially filled container of lettuce salad with grated cheese contained no date or name to identify the owner. The surveyor asked EI #6 whose salad it was. EI #6 did not know. One of the nurses in attendance was also unaware who owned the salad. When asked whose responsibility it was for monitoring the contents of the refrigerators, EI #6 replied all the staff were responsible. The surveyor asked how often the staff checked the contents of the nursing refrigerators. EI #6 explained Dietary checked the refrigerators once a week, and each (nursing) department checked their refrigerator every day (verified by the attending nurse, EI #9). When asked what potential problem could result with unlabeled or outdated food. EI #6 explained residents might get a hold of the food, eat it and get sick. Station 3 On [DATE] at 5:14 pm, EI #6 and the surveyor observed the following in the Station 3 refrigerator: a) The freezing compartment contained two 1.5 quart containers of Butter Pecan ice cream (one of which was nearly empty, the other unopened); one frozen quesadilla, one packaged uncooked hot pocket, and one unopened package of Chicken Fettuccine dinner. None of these food items were labeled with a name. b) The refrigeration unit contained one carton of Mighty Shake with no labeled use-by date. When interviewed at 5:14 PM, the Unit Manager (EI #7) stated all of the unlabeled frozen food items belonged to one particular resident, giving no further explanation. 6) UNSANITARY REFRIGERATION UNITS The (YEAR) FOOD CODE mandates under ,[DATE],11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. On [DATE] at 5:14 PM, the freezing compartment of the Station 3 refrigerator contained a large area of melted ice cream and other spills, evidence of the lack of cleaning for an extended period of time. The refrigeration unit contained a large spill of brown liquid in the bottom of the vegetable drawer. On [DATE] at 5:15 PM, the Assistant Dietary Manager (EI #6) and the Station 3 Unit Manager (EI #7) were asked whose responsibility it was for cleaning the refrigerator. Both EI #6 and EI #7 confirmed each nursing unit was responsible for cleaning their own refrigerator. In response to a question of cleaning frequency, EI #7 stated the night shift (11 PM to 7 AM) was to clean the refrigerator each Thursday. EI #7 affirmed the refrigerator needed cleaning.

Based on observations, interviews and a review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013, the facility failed to: 1. assure wiping cloths were stored in a sanitizing solution, 2. assure dented cans were removed from the active inventory, 3. assure effective cleaning/sanitizing of utensils and equipment to prevent the potential growth of food borne organisms, a. assure flatware (spoons) were air dried prior to use (machine dishwashing), b. assure dinnerware, sectional plates, was cleaned to sight/touch (machine dishwashing) and c. assure equipment, a Tea Urn/spigot a non Time/Temperature control for safety, was cleaned every 24 hours. The spigot was observed with a brown solid build-up. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect 167 residents who received meal trays from dining services. 177 residents reside in the facility. Findings include: 1. A record review of the 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: .3-304.14 Wiping Cloths, Use Limitation. .(B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified . An observation on 01/31/2018 at 9:52 AM, was made of a wiping cloth not in use and not stored in a chemical solution. The cloth was placed on top of a cart which held a tray of snacks. At 11:05 AM, a wet cloth was observed to be left on the steamtable serving board. An interview with the Certified Dietary Manager (CDM), EI (Employee Identifier) #3 was conducted shortly after the observation was made. EI #3 was unable to explain why staff was non-compliant, but stated there would be a potential risk for cross-contamination. 2. An observation on 01/30/2018 at 2:35 PM of the dry storage area, revealed a #10 can of mild cheese sauce stored on a rotation can rack for current use. The can was severely dented and the seal was compromised. During a morning interview with EI #3 on 2/01/2018, she was asked why the can had not been removed. EI #3 stated it was staff oversight and there would be a possible risk for bacterial contamination if used. 3a. A record review of the 2013 Food Code by the USPHS and the FDA included the following: .4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . An observation on 01/31/2018 at 10:08 AM, revealed a buspan filled with soiled flatware. The buspan was void of a soaking solution/water. A FSW (Food Service Worker) was transferring the buspan to the dishmachine window. At 11:00 AM, two FSW's were observed bagging flatware into a sleeve to place on resident meal trays. The eating utensils were sorted into cylinders. The surveyor selected six spoons which were nested in the cylindrical container. The six spoons were fanned out in the presence of the Registered Dietitian, EI #4. The six spoons were wet and not air dried. Food debris was observed inside the spoon bowls. On 2/01/2018 at 4:42 PM, the CDM, EI #3, was asked why there was food debris. EI #3 said, probable failure to pre-soak, which created a risk for bacterial contamination. 3b. On 01/31/2018 at 09:35 AM, an observation was made of clean/sanitized sectional plates stored on a cart in the dishroom awaiting transport to the trayline. Four of four sectional plates were stacked (not inverted). All four contained water and one had food debris on the cross section. On 02/01/2018 at 9:35 AM , an interview with the CDM, EI #3 revealed she was unsure why the plates were not inverted, but would follow-up. EI #3 stated there was a potential risk for bacterial contamination. 3c. A record review of the 2013 Food Code by the USPHS and the FDA included the following: .Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (E) .surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: .(2) At least every 24 hours for iced tea dispensers . An observation on 01/30/2018 at 2:55 PM was made of a five gallon tea urn container. A request was made for the CDM, EI #3, to disassemble the faucet. EI #3 broke the spigot down into one part. The surveyor requested another part be broken down . The CDM did so and a brown area encircled the top internal area. The CDM used a fingernail to remove a portion of the build-up. During an interview on 02/01/2018, at 3:58 PM, EI #3 was asked why there was a brown build-up. EI #3 said there was a failure to completely disassemble the parts and there would be a potential for cross-contamination.

Based on interview and medical record review, the facility failed to ensure Hospice was correctly identified on the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/09/17, for Resident Identifier (RI )# 12. This affected one of three residents sampled for Hospice. Findings Include: RI #12 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI # 12's physician's orders [REDACTED].HOSPICE TO TREAT FOR [MEDICAL CONDITION] . A review of RI #12's MDS with an ARD of 11/09/17, did not reflect RI #12 was receiving Hospice. An interview was completed on 02/01/18 at 12:17 p.m. with Employee Indentifer (EI) #2, Registered Nurse. EI #2 was asked if RI #12 was currently on Hospice. EI #2 responded yes. EI #2 was asked if the 11/09/17 MDS reflected RI #12 was receiving Hospice. EI #2 responded no. EI #2 was asked if the 11/09/17 MDS should be coded for Hospice. EI #2 responded yes. EI #2 further stated she forgot to check Hospice. EI #2 was asked why should the MDS be coded for Hospice. EI #2 stated so it would reflect the resident was receiving Hospice.

Based on interview, medical record review and Potter and Perry's Fundamentals of Nursing, the facility failed to obtain a discharge order for Resident Identifier (RI) #98 when he/she was discharged from Hospice on 12/25/18. This affected one of three residents reviewed for Hospice. Findings Include: A review of Potter and Perry's, Fundamentals of Nursing, Ninth Edition, Chapter 23, Legal Implications in Nursing Practice, page 311, Health Care Providers' Orders, revealed: .The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders .Make sure that all the health care providers orders are .dated and timed appropriately . RI #98 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of a facility document titled, Notice of Medicare Non-Coverage with RI #98's name documented on it revealed: .Hospice Services Will End: 12-25-17 . A review of RI #98's Physician order [REDACTED].Stop .HOSPICE CARE DISCONTINUED DUE TO NO LONGER MEETING CRITERIA . An interview was conducted with Employee Identifier (EI) #5, Licensed Practical Nurse (LPN) on 02/01/18 at 3:13 p.m. EI #5 was asked if RI #98 was currently on Hospice. EI #5 replied he/she came off on January 2, 2018, due to no longer meeting criteria. An interview was conducted with EI #6, Director of Nursing on 02/01/18 3:39 p.m. EI #6 was asked when RI #98's Hospice services ended. EI #6 replied on 12/25/17, but they did not stop it in the computer until 01/02/18. EI #6 was asked when did the facility obtain the order to stop Hospice for RI #98. EI #6 replied, according to the physician's orders [REDACTED].#6 was asked when should the facility have received the order to stop Hospice for RI #98. EI #6 stated on 12/25/17, when services ended.

Based on an interview and a review of a policy titled, Federal Rights of Resident/Guest(s) the facility failed to ensure mail was delivered to residents on Saturday. This affected 12 residents who attended the Resident Council Meeting on 1/31/18, and had the potential to affect all residents in the facility. Findings Include: A review of a policy titled, Federal Rights of Resident/Guest(s) with an effective date of November 28, 2016, documented the following: .(g)(8) The resident/guest has the right to .receive mail .(h) .The facility must respect the resident/guest(s) right to personal privacy, including the right to promptly receive .mail . On 01/31/18 at 10:15 AM during the Resident Council Meeting, 12 residents reported mail was not delivered on Saturday. An interview was conducted with Employee Identifier (EI) #1, Activities Director, at 11:15 AM. EI #1 was asked if mail was delivered on Saturday. EI #1 responded it was delivered Monday - Friday and early Monday morning they delivered the Saturday mail. EI #1 was asked why mail was not delivered on Saturday. EI #1 responded because there was no activity staff to deliver it on Saturday. EI #1 further stated the activity staff worked Monday - Friday. EI #1 was asked why mail should be delivered on Saturday. EI #1 stated because the resident would not receive it until Monday. EI #1 was asked if mail was delivered to the facility on Saturday. EI #1 responded yes, the postman brought it into the facility and it was placed in a slot by the office.

Based on observations and interview, the facility failed to ensure there was not a black buildup around the baseboards and doorways and the ceiling tiles were not broken, rusty and dusty on Unit 1. This deficient practice was observed on Unit 1, one of four units in the facility. Findings include: During the initial tour of the facility on 11/8/2016 at 11:18 AM, there was a black buildup around the baseboards and doorways on Unit 1. On 11/9/2016 at 3:20 PM, the ceiling vents and air return vents in the hallway of Unit 1 were observed to be rusty with dust bunnies hanging from them. Two ceiling tiles were also noted to be broken in the hallway on Unit 1. In an interview on 11/10/2016 at 11:39 AM, Employee Identifier (EI) #3, a Maintenance Supervisor was asked, what was the problem with the air vents on Unit 1 being rusty with dust hanging from them. EI #3 stated, the dust is being blown into the halls and it's been breathed in by the residents. When asked, why are the ceiling tiles broken, EI #3 stated, the ceiling tiles were probably broken within the past three weeks when the lights were replaced.

Based on record review and interview, the facility failed to ensure Resident Identifier (RI) #17's quarterly Minimum Data Sets ((MDS) dated [DATE] accurately reflected RI #17 received Insulin. This affected one of 23 sampled residents whose MDS assessments were reviewed. Findings include: RI #17 was readmitted to the facility on [DATE],with a medical history to include a [DIAGNOSES REDACTED]. RI #17's Quarterly MDS dated [DATE] did not indicate the resident received Insulin. RI #17's physician's orders [REDACTED].#17 was ordered [MEDICATION NAME] (Insulin) every night at bedtime for Type 2 Diabetes with [MEDICAL CONDITION]. An interview was conducted on 11/10/2016 at 2:30 PM, with Employee Identifier (EI) #1, the Registered Nurse (RN)/MDS Coordinator. She was asked who was responsible for RI #17's MDS. EI #1 stated, I am. EI #1 was asked if RI #17 received Insulin for Type 2 Diabetes Mellitus. She stated, Yes. When asked, why the MDS did not indicate RI #17 received Insulin. She stated, I don't know if it's a computer error or my error. EI #1 was asked if the assessment was accurate. She stated, No. She was asked what the potential for harm was if the assessment was not accurate. EI #1 replied, if someone looked at the MDS they might not know the resident receives insulin.

Based on observation, interviews and record review, the facility failed to ensure Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) did not clean Resident Identifier (RI) #4 in a back to front motion while cleaning the resident's anal area. This affected one of two residents observed for incontinent care. Finding include: A facility's policy titled Perineal Care with an effective date of 10/1/2010, documented PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdown . III. Male Resident . b) Turn resident onto side. Wash, rinse and dry the anal area, moving upward toward the back. RI #4 was readmitted to the facility on [DATE]. RI #4's Significant Change in Status Minimum Data Set with an assessment reference date of 8/25/2016 documented RI #4 required extensive assistance of one person for toileting and was always incontinent of bowel and bladder. During an observation of incontinent care for RI #4 on 11/9/2016 at 4:00 PM, EI #4 (CNA) obtained a clean wipe and used a back to front motion twice while cleaning the resident's anal area. During a telephone interview on 11/10/2016 at 3:40 PM, EI #4 (CNA) acknowledged he provided incontinent care to RI #4 on 11/9/2016. EI #4 was asked what direction he should use while cleaning a resident's anal area. He replied, front to back. EI #4 was asked what direction he used while providing care for RI #4. He replied, a back to front. When asked if he was aware he had used a back to front motion while cleaning RI #4's anal area, EI #4 replied, No after I thought about it I beat myself up I knew I did it wrong. EI #4 was asked what the potential for harm was for using a back to front motion while cleaning the anal area. He stated, Cross Contamination.

Based on observations, interviews and record reviews the facility failed to ensure Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) removed dirty gloves and washed his hands before touching Resident Identifier (RI) #4's clean incontinent brief. This deficient practice affected RI #4, one of two residents observed for incontinent care. The facility further failed to ensure EI #6, a Licensed Practical Nurse (LPN) washed her hands and wore gloves when she administered eye drops to RI #17. This deficient practice affected RI #17, one of three residents observed for medication administration. Findings include: 1) A facility's policy titled Hand Hygiene (IC.VI-4) with an effective date of 12/1/2009, documented PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. STANDARD: Hand washing should be performed between procedures with residents based upon the principle that all . body fluids, . excretions . may contain transmissible infectious agents . RI #4 was readmitted to the facility on [DATE]. During an observation of incontinent care for RI #4 on 11/9/2016 at 4:00 PM, EI #4 (CNA) did not remove his gloves after he had cleaned RI #4's groin area or before he placed a clean brief on the resident. A telephone interview was conducted with EI #4 on 11/10/2016 at 3:40 PM. EI #4 was asked if he removed his dirty gloves, washed his hands and applied clean gloves before touching RI #4's clean brief. EI #4 stated, I did not. EI #4 was asked why and he stated, I was nervous. He was asked what the potential for harm was if dirty gloves are used to apply a clean brief and touch the residents sheets. EI #4 stated, Cross Contamination. An interview was conducted with EI #5, the Infection Control Registered Nurse on 11/10/2016 at 11:40 AM. EI #5 was asked what was the facility's policy related to hand washing and putting on gloves between dirty and clean. She replied, wash hands and put on new gloves after cleaning and before touching clean items. She was asked what the potential for harm was if a CNA used the same gloves used to clean a resident after incontinent care to apply a clean brief and touch a residents sheets. EI #5 stated, Contamination. 2) A facility's policy titled . Medication Administration - General Guidelines with an effective date of March 2011, documented . Procedures . 6. Cleanse hands with soap and water before handling medication and before and after direct contact with resident. (Other examples where this would be necessary are when administering . ophthalmic . medications.) . 19. Gloves should be worn when there is a potential for exposure to resident's . secretions, . or mucous membranes . During medication administration observation on 11/8/2016 at 5:10 PM, EI #6, a Licensed Practical Nurse (LPN) did not wash her hands or put on gloves when she administered eye drops to RI #17. An interview was conducted with EI #5, the Infection Control Nurse/Director of Nursing, on 11/10/2016 at 11:40 AM. She was asked if a nurse should wash their hands and put on gloves before administering eye drops. EI #5 replied, yes. EI #5 was asked what the potential for harm was if an LPN fails to wash her hands and put on gloves before administering eye drops to a resident. She stated, Potential for Infection. During an interview on 11/10/2016 at 3:05 PM, EI #6 (LPN) was asked why she administered eye drops to RI #17 without washing her hands and putting on gloves. EI #6 replied, that she was not just not thinking. EI #6 was asked what the potential for harm was if she failed to wash her hand and apply her gloves before administering eye drops. She stated, cross contamination.

Based on observation and interview, the facility failed to ensure the shower room on Unit Four across from the nursing station was equipped with a call light system to alert staff when a resident and or/staff required assistance during the showering process. This had the potential to affect all residents who reside on Unit Four of the facility. Findings include: A facility's policy titled Answering the Call Light with an effective date of October 1, 2010 revealed the following: PURPOSE: Call light serve as notice to the staff the resident has a need or request . On 11/10/2016 at 11:20 a.m., while on a facility tour with Employee Identifier (EI) #3, a Maintenance Supervisor, the surveyor observed there was not a call light present in the shower room across from the nursing station on Unit Four. EI #3 stated the room had been converted in 2005 from a linen closet to a shower room and acknowledged there was no call light in the shower room. On 11/10/2016 at 11:39 a.m., EI #3 was asked what was the potential harm in not having a call light in the shower room on Unit Four. EI #3 replied, a resident could get in there and fall and not able to get help or an employee could need help.

Based on observation, interviews, record reviews, the review of documents provided by the facility titled, "Secure P. A. D. S. (The Personal Accident Deterrent System) Bed Sensor" and "UNIVERSAL ALARM" the facility; a) failed to ensure resident Resident Identifier (RI) #1, who is cognitively impaired, assessed as being at high risk for falls, with a history of falls with fractures, was provided adequate supervision and monitoring to prevent RI #1 from falling on five different occasions in less than 2 months. All five falls were un-witnessed by facility staff. One fall resulted in RI #1 being admitted to the hospital for treatment. Fall #1 occurred on 3/05/2012 at 2:20 pm. RI #1 was left unattended in her room. RI #1 fell from her wheelchair and sustained a closed head injury and contusion to her right wrist. Consequently this fall with injuries resulted in RI #1 being hospitalizated for treatment. During Fall #2, on 3/30/12 at 6:20 am, Fall #3 on 4/15/2012 at 3:00 pm and Fall #4 on 4/16/2012 at 2:56 am, the bed alarm did not sound to alert the staff that RI #1 had raised from bed. The facility was unable to explain why the alarm did not sound. Fall # 5, on 4/17/2012 at 6:11 pm, RI #1 was left unattended at the nurse's station , resulting in RI #1 flipping over in her wheelchair. b) failed to ensure RI #3's alarm sounded to prevent him from falling. RI #3, a resident at risk for falls and who is known to rise unassisted, had two falls within a three month time frame in which his alarm did not sound. During Fall #1, on 1/29/2012 at 12:11 pm and Fall #2, on 4/05/2012 at 12:27 pm, the chair pressure alarm did not sound to alert the staff that RI #3 was rising from the chair and RI #3 fell on both instances. The facility was unable to explain why the alarm did not sound. c) failed to ensure that bed and chair alarms were present and functioning properly to alert staff that residents at risk for falls were attempting to raise from their chair or bed for eight residents. On April 18, 2012, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Stations 1, 2, 3, and 4 Unit Managers toured the facility with the surveyor. Twenty-seven residents were identified by the facility as using bed and/or chair alarms as fall precautions. Eight residents, (RI # 4, 5, 6, 7, 8, 9, 10, and 11) were observed and determined their alarms did not alarm when activated or were not in use when the resident was in bed or sitting in a chair. These deficient practices affected RI #(s) 1, 3, 4, 5, 6, 7, 8, 9, 10 and 11, 10 of 11 sampled residents who were assessed as being at risk for falls, with alarms and had the potential to affect the 17 residents identified by the facility at risk for falls with alarms. Findings Include: a) RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/27/2012 has RI #1 assessed as having a Brief Interview for Mental Status (BIMS) score of 4 (a score of 0 - 7 indicates that the resident has severe cognitive impairment). RI #1 is assessed as requiring extensive assist of one with bed mobility, transfers, dressing and toileting. RI #1 is assessed as being frequently incontinent of bowel and bladder. RI #1's Care Area Assessment for Falls, from the Annual MDS, with an ARD date of 6/10/2011 documents that RI #1 is at risk for falls due to a previous fall, impaired balance during transition, her balance is unsteady and requires assist of one with transfers, medications; such as Antipsychotics, Antianxiety agents and Antidepressants, and Parkinson's disease. RI #1's Care Plan for falls with a problem onset date of 12/14/2007 and a review dated of 2/24/2012 documents, "...Potential for falls R/T (related to) WEAKNESS, Parkinson's, Neuropathy, Osteoporosis, CVA (cerebral Vascular Accident), Dementia; impulsivity; (08/12/08 non-compliance with calling for help, poor safety awareness) ..." RI #1's Fall Care Plan documents approaches including bed in low position, a high back wheelchair with a seat cushion and Velcro seatbelt with alarm, bed alarm, encourage use of handrails / appropriate assistive devices and to ensure bed alarm is working. According to RI #1's "Departmental Notes," dated 2/18/2012 she was admitted to a local hospital with [DIAGNOSES REDACTED]. According to RI #1's "Departmental Notes," dated 2/24/2012 she was readmitted to the facility on [DATE] at 4:25 pm. On 3/05/2012 at 2:20 pm RI #1 experienced a fall at the facility. The facility's "Resident Incident Report" for RI #1 completed by EI #4, a facility Licensed Practical Nurse (LPN), documents, and " ... Activity at time: From chair w/o (without) asst (assist) Witness 1. (E1 #4's name) Witness (EI #5's name) ... Narrative of incident and description of injuries: Resident (RI #1) found on floor in room with wheelchair in doorway. Room clutter free, Floor wet next to where resident was lying. Resident in room on floor, lying on Lt (left) side. Large hematoma with bruising noted to forehead. Small abrasion on Lt side of nose, with scant amount of bleeding, easily controlled. Area cleansed. Resident eyeglasses lying under residents face. Family & (and) MD (Medical Doctor) notified. (name of local ambulance service) service called for transportation to (name of local hospital) for evaluation of hematoma. ..." The facility's "Incident Investigation," completed by EI #3 regarding the fall of 3/05/2012 documents, "... Narrative of investigation: Resident was found on floor in front of w/c. Staff was getting ready to place resident in the bed at this time when they came back resident had fallen out of w/c at this time, floor was wet next to resident unable to determine if it was water or urine. Resident noted with hematoma to forehead. Neurochecks where performed and resident was sent to hospital at the time. Will get OT (Occupational Therapy) to eval resident for positioning while up in chair. ..." The "Physician Documentation," with a report date and time of 3/05/2012 at 1527 (3:27 pm), for RI #1 from the local Hospital documents, "History of Present Illness ... Triage History ...: PT (patient) BROUGHT PER (name of nursing home) AFTER FALLING OUT OF HER (RI#1) W/C (wheelchair), STAFF STS (states) - (no) LOC (loss of consciousness), LARGE HEMATOMA NOTED TO LEFT SIDE OF FOREHEAD AND SMALL CUT NOTED TO BRIDGE OF NOSE, PT ABLE TO CONVERSE AND ALERT PT HER BASELINE. PUPILS EQUAL AND REACTIVE. PT ON ASPIRIN THERAPY. ... Physical Exam Exam Findings ... Skin: 5 cm (centimeter) to left side of forehead ... Head: Atraumatic and normalcephalic. 1/3 shallow cm laceration to left nose ... Extremities: Right wrist contusion... ED Course: ... 1943 (7:43 pm): I discussed the patients condition and plan for admission with Dr. (residents MD) who agrees with plan for admission and assumes care at this time. ... Certified Medical Emergency: Yes Clinical Impression: 1. ACUTE ALTERED MENTAL STATUS 2. CLOSED HEAD INJURY 3. PARKINSON'S DISEASE 4. SIMPLE LACERATION LEFT NOSE 5. CONTUSION RIGHT WRIST ..." RI #1's "Departmental Notes," dated 3/06/2012 at 4:40 pm documents, "Resident arrived back to the facility @ (at) 4:20 pm via (name of local ambulance) per stretcher. ... Resident noted to have a sling in place to right arm. Resident able to perform ROM with right arm w/o (without) c/o (complaint of) pain. Noted to have purple area under right eye and purplish all around left eye. Also noted hematoma above left eye..." On 4/18/2012 at 1:29 pm, EI #5, a facility CNA, was interviewed by the surveyor regarding RI #1's fall on 3/05/2012. EI #5 was given the incident report to review. EI # 5 stated that RI #1 was not her resident that day she was taking care of another resident. EI #5 stated that she saw RI #1 leaning to pick something up and she told RI #1 to sit up and she said ok. EI #5 stated when she was taking care of her resident she heard a loud noise and when she turned around RI #1 was on the floor. EI #5 was asked where RI #1 had been sitting prior to the fall. EI #5 stated that RI #1 was at the nurse's station and her CNA, later identified as EI #6, was getting ready to check RI #1 and had asked her to help. EI #5 stated EI #6 pushed RI #1 to the doorway of her (RI #1's) room and remembered she (EI #6) needs something. EI #5 stated that when EI #6 went to get what it was she needed she (EI #5) went to check her resident and did not even make it into the room before RI #1 had fallen. EI #5 was asked if she saw RI #1 fall. EI #5 stated she did not see RI #1 fall, she only heard a loud thump. EI #5 asked if she saw RI #1 leaning and she knew EI #6 had left, why she would leave RI #1 unattended. EI #5 stated she told EI #6 she was going to check her resident. EI #5 was asked if RI #1 had on an alarm. EI #5 stated that EI #6 had put the seatbelt alarm on earlier and was told by the Unit Manager, EI #3, to remove it because RI #1 had to be reassessed. EI #5 was asked what RI #1 hit. EI #5 stated the floor face first. EI #5 was asked what happened when the nurse got to RI #1. EI #5 stated EI #4 went straight to the floor and stated not to move RI #1 because she saw blood. EI #5 stated that there was a liquid on the floor but she did not know what it was. EI #5 stated that EI #4 stayed with RI #1 until the paramedics came and got RI #1. On 4/20/2012 at 4:31 pm, a phone interview was conducted with EI #6, the CNA assigned to RI #1 on the day of the fall, regarding RI #1's fall on 3/05/2012. EI #6 stated she remembered the fall because RI #1 was the first resident that ever fell on her. EI #6 stated it was around 2 o'clock and she was making her rounds. RI #1 was at the nurse's station and she rolled RI #1 to the door of her room and asked EI #5 to help her. EI #6 stated she remembered she needed a towel and ran to get it. EI #6 commented that she wasn't gone a minute and when she returned RI #1 was on the floor. EI #6 stated RI #1 was not leaning she had only gotten her up after lunch so she was not tired. EI #6 stated RI #1 did not have on her seat belt because she had put it on earlier and EI #3 had told her that RI #1 did not have an order for [REDACTED].#3 if she wanted her to remove it and EI #3 stated yes and she removed it. EI #6 was asked if she did not have what she needed why she did not take RI #1 with her. EI #6 stated that she left RI #1 with EI #5 so it was not like RI #1 was alone. EI #6 stated when she asked EI #5 why she wasn't with RI #1, EI #5 stated she had told her she would be right back. EI #6 stated she did not hear EI #5 say that. On 4/18/2012 at 2:25 pm, EI #4, a facility Licensed Practical Nurse (LPN), was interviewed by the surveyor regarding RI #1's fall on 3/05/2012. EI #4 stated that she was at the nurse's station when she heard a thump. EI #4 stated she jumped up and ran down the hall to find RI #1 on the floor. EI #4 stated she saw RI #1's wheelchair in the doorway of the room and RI #1 was on the floor closest to the television. EI #4 stated she thought EI #3 was right behind her and that ' s when she saw the huge hematoma on RI #1's forehead. EI #4 commented it was obvious she had hit her head. EI #4 stated she immediately asked for help and asked what happened. EI #4 stated RI #1 was shaking really bad and was not as alert as she was now. EI #4 stated RI #1 asked to help her up. EI #4 stated when she assessed RI #1 she saw a small abrasion on her nose where RI #1's glasses had hit. EI #4 stated RI #1 was gotten up and placed in her wheelchair. EI #1 ' s vital signs were taken. EI #4 was asked if she determined why RI #1 had fallen. EI #4 stated not really that she EI #5 stated she was walking by and the CNA's were making rounds. EI #4 stated RI #1 was a fall risk because she had fallen before. EI #4 stated RI #1 had a Velcro seatbelt in place to her wheelchair but it was not in place. The surveyor asked EI #4 why it was not in place. EI #4 stated she had placed the seatbelt on RI #1 earlier that day and she was told by her supervisor, EI #3, that RI #1 had to be reassessed before she could wear the seatbelt. EI #4 was asked if she could not use the seatbelt what she did. EI #4 stated she could have put a chair alarm but when she worked she kept RI #1 with her and gave her things to do so she knew where she was. EI #4 was asked what interventions were put in place after RI #1's fall. EI #4 stated the seatbelt was put back on, RI #1 already had a bed alarm and because she was leaning in the wheelchair, therapy placed a cushion like device in the wheelchair to keep her from leaning. EI #4 commented that RI #1 had not been leaning before the fall. On 4/18/2012 at 3:30 pm, EI #3, Station 3 Unit Manager, was interviewed by the surveyor regarding RI #1's falls. EI #3 was asked was RI #1 a fall risk. EI #3 stated she had a history of [REDACTED].#1 returned from the hospital on [DATE]. EI #3 stated RI #1 had a bed alarm, a scoop mattress and the seatbelt was not because the restorative LPN stated RI #1 needed to be reassessed before it could be used. EI #3 commented that she told staff to let her know when RI #1 was in the chair. After reviewing RI #1's record with EI #3 showing where RI #1's last fall was 11/14/11 and had episodes of trying to get up and removing seatbelt, EI #3 was asked why she did not try and get the evaluation as soon as she returned. EI #3 stated an evaluation was done but when RI #1 returned she was so lethargic they could not do much. EI #3 was asked when RI #1 started getting up why wasn't a chair alarm put in place. EI #3 stated because the seatbelt was on the chair if she needed it. EI #3 was asked what the staff had been told regarding monitoring and supervising RI #1. EI #3 stated the staff was told to make sure she was not leaning and if she did, to place the seatbelt on her. EI #3 was asked why she had staff to remove the seatbelt on the day of her fall. EI #3 stated because RI #1 was not approved to wear it and she was not trying to get up or leaning. EI #3 stated on the day of RI #1's fall she was in her office. She had been told the CNA was getting ready to change RI #1 and forgot something and when she returned RI #1 was on the floor. EI #3 was asked if she determined why RI #1 fell . EI #3 stated that maybe RI #1 fell asleep and fell out of the chair. After RI #1's fall EI #3 stated OT worked with RI #1 to determine if the wheelchair was appropriate and she started using the seatbelt again. EI #3 was asked what was put in place to ensure RI #1 was supervised and monitored. EI #1 stated staff was watching her, her daughter started coming to the facility more and between rounds RI #1 was watched behind the nurses' station. On 4/16/2012 at 5:41 pm, during the initial tour the surveyor observed a female resident, later identified as RI #1, rolling around from the dining room to the hallway. RI #1 had a seat belt in place and stated to surveyor that she had fallen out of the bed that morning (4/16/2012). A nurse was in the hallway and surveyor asked nurse about the fall. The nurse stated she fell on yesterday (4/15/2012). While in the hallway a CNA walked up and called the resident by name and asked if she wanted her to push her down the hallway. RI #1 stated yes and was taken down the hall. RI #1 was observed continuously from 5:51 pm until 6:57 pm. The following was observed: At 5:51 pm, RI #1 was rolling around in the hallway without staff monitoring or supervision. At 6:01 pm, RI #1 was observed rolling from the end of the hall back to the nurse's station, without staff monitoring or supervision. At 6:10 pm, RI #1 was observed to roll around the nurse's station, without staff monitoring or supervision. At 6:12 pm, RI #1 was observed to play with a food tray on a cart in front of the nurse's station. Three nurses were at the nurse's station and no one responded to RI #1. RI #1 removed a cup from the tray. A visitor intervened as RI #1 removed the lid from the cup. The visitor asked the nurses if the cup belonged to RI #1. A nurse, writing at the nursing station, looked up then came from behind the desk. The visitor gave the cup to the nurse. The facility staff did not ask RI #1 if she wanted something to drink but returned to behind the desk and RI #1 rolled back down the hallway. At 6:17 pm, RI #1 was observed to release the seatbelt causing it to making a beep sound. A nurse came from behind the nurse's station, reattached the seatbelt and told RI #1 it was a reminder. RI #1 was observed to continue to roll in the hallway, without staff monitoring or supervision. At 6:22 pm, RI #1 was observed to roll into the nurse's station and stated she was trying to get to refrigerator. A nurse asked RI #1 if she wanted some ice cream. At 6:24 pm, the nurse with a small cup escorted RI #1 to her room and was observed to give RI #1 the ice cream. At 6:30 pm, the surveyor observed the nurse return to the desk with RI #1, and RI #1 continued to roll around. At 6:32 pm, RI #1 was observed to roll to the desk and asked the nurse to lay her down. RI #1 was told by nurse as soon as the CNA's finished feeding they would lay her down. RI #1 was observed to roll away from the nurse's station down the hallway. At 6:38 pm, RI #1 continued to roll around in the hallway, without staff monitoring or supervision. At 6:44 pm, the CNA was observed to go and get RI #1 from the hallway and took her to the room and began to close the door. The surveyor knocked on the door and continued to observe RI #1. After the CNA had changed RI #1's shirt, RI #1 was left unattended in her room in her wheelchair with the seatbelt in place. At 6:47 pm, RI #1 was observed in her room unattended leaning forward in her wheelchair. At 6:50 pm, RI #1 remained in her room unattended sitting in her wheelchair with the seatbelt in place. At 6:51 pm, RI #1, still in her room, was observed attempting to rise numerous times from the wheelchair. The attached seatbelt wound not allow her to get out of the chair. At 6:52 pm, RI #1 was at a standing position when the CNA passed her room and asked her to not try and get up. The CNA pulled RI #1's gown down and again left RI #1 in her room unattended. The CNA returned to the nurse's station. At 6:54 pm, RI #1, unattended in her room, was observed continuing trying to stand. At 6:55 pm, the surveyor observed staff enter RI #1's room and stated they were going to lay her down. At 6:57 pm, RI #1 was placed in bed. On 3/30/2012 at 6:20 am, RI #1 experienced a second fall at the facility. The facility's "Resident Incident Report", completed by EI #7, for RI #1, documents, "... Activity at time: From bed w/o (without) asst (assist) Witness 1. (E 1 #7's name) Witness (EI #8's name) ... Narrative of incident and description of injuries: Resident found sitting on the floor next to bed. Bed in low position ... Resident unable to state how she got there, but indicate that she was wanting to get to her chair. ... Resident brief and clothing wet. Resident was assisted to bed, cleaned and dried, and day clothes were put on resident. Redness to lower left abdomen. ..." The facility's "Incident Investigation," completed by EI #3 regarding RI #1's falls of 3/05/2012 documents, "... Narrative of investigation: Resident was found on the floor by staff after she had gotten up out of bed unassisted, resident was trying to get out of bed and go to recliner chair. Nurse stated alarm was sounding at 5:50 am when she went in room and staff repositioned resident in bed. While staff was in the room tending to other resident, resident got up and was found on floor. resident alarm did not sound. Resident alarm noted with malfunction, alarm replaced at this time. .." RI #1's "Departmental Notes," dated 3/30/2012 and signed by EI #3 documents, "...Role: Unit Supervisor ... Resident reviewed in idcp (interdisciplinary care plan) meeting had a fall this morning when resident got up out of bed without assistance, residents had bed alarm and it was sounding prior to fall but did not sound at time of fall, bed alarm replaced at this time. No injuries noted..." On 4/18/2012 at 11:42 am, EI #8, a facility's Nurse Assistant (NA), was interviewed by the surveyor regarding RI #1's fall of 3/30/2012. EI #8 stated that she had the curtain pulled working with RI #1's roommate and when she finished she pulled the curtain and saw RI #1 sitting on the floor with her back to the bed. EI #8 stated when she asked RI #1 what happen RI #1 stated said she was trying to get to the chair. EI #1 stated she then got the nurse. EI #8 stated RI #1 had a bed alarm and described it as being a flat one under the sheets. EI #8 stated the alarm did not sound and she did not know why. EI #8 was asked if she checked the alarm. EI #8 stated she did not and commented she did not know how to check it. EI #8 stated she had been in the room about 7 minutes or more and did not hear RI #1 come out of the bed. On 4/19/2012 at 8:24 am, EI #7, a facility LPN, was interviewed by the surveyor regarding RI #1; s fall on 3/30/2012. EI #7 stated that RI #1 was sitting on the side of the bed and did not know she could move that well. EI #1 stated she did not know why RI #1 was getting out of bed but when she asked what happen RI #1 pointed to the chair which led her to believe she was trying to get into the chair. EI #7 stated she could not remember if the alarm was sounding, but that when RI #1 wiggles the alarm goes off. EI #7 stated that the NA was in the room and when she pulled the curtain to leave she saw RI #1 on the floor. EI #7 stated that the last time she saw RI #1 was around 5:00 or 5:30 her alarm was going off as she went and repositioned her that why she was surprised it did not go off when she fell . EI #7 was asked how long the pressure alarms sound after a resident comes out of bed. EI #7 stated indefinitely until you turn them off or reset them. On 4/18/2012 at 3:30 pm, EI #3, Station 3 Unit Manager, was interviewed by the surveyor regarding RI #1's falls. EI #3 was asked what the reason was for the fall of 3/30/2012. EI #3 stated RI #1 was trying to get out of bed to the recliner (chair). EI #1 was asked what was wrong with the alarm. EI #3 stated she checked it then replaced it with a new box. EI #3 stated it would not sound and she did not know what was wrong. EI #3 was asked what interventions were put in place. EI #3 stated staff was told if RI #1 got restless at night to get her up. On 4/15/2012 at 3:00 pm, RI #1 experienced a third fall at the facility, sixteen days after her last fall. The facility's "Resident Incident Report" for RI #1 completed by EI #9, a facility Licensed Practical Nurse (LPN), documents, and " ... Activity at time: From bed w/o (without) asst (assist) Witness 1. (E 1 #9's name) Witness (EI #10's name) ... Narrative of incident and description of injuries: Called to residents room per staff to find resident sitting on the floor at the head of bed on her bottom. Resident had no shoes on. ... Alarm was not sounding ... Resident stated "i was trying to put on my shoes". Resident lifted off the floor x 3 staff. ..." The facility's "Incident Investigation," completed by EI #3 regarding RI #1's fall of 4/15/2012 documents, "... Narrative of investigation: Called to residents room per staff it finds resident sitting on floor at head of bed on her bottom ... Resident had no shoes on. ... Alarm not sounding. ... Immediate Action Taken: resident lifted off the floor and put in bed then placed in chair. ..." On 4/15/2012 at 6:30 pm, RI #1 experienced a fourth fall at the facility, less than four hours after having a fall from the bed. The facility's "Resident Incident Report" for RI #1 completed by EI #12, a facility Licensed Practical Nurse (LPN), documents that a staff member EI #11 heard the alarm sounding and found RI #1 on the floor beside the bed. EI #12 documented that RI #1 was found by a facility CNA on the floor beside her bed. The facility's "Incident Investigation," completed by EI #3 regarding RI #1's fall of 3/05/2012 documents, "... Narrative of investigation: Resident was found on the floor by staff after she had gotten up out of bed unassisted and found sitting on the floor. Residents alarm was sounding at time of fall. Resident has had some increased restlessness noted Will notify md for possible medication changes ..." On 4/16/2012 at 3:00 pm, RI #1 experienced a fifth fall at the facility, less than nine hours after her last fall and the third fall in 12 hours. The facility's "Resident Incident Report" for RI #1, completed by EI #7, a facility LPN, documents, "... Activity at time: From bed w/o (without) asst (assist) Witness 1: (EI #13's name) Witness 2: (EI #7's name) ... Narrative of incident and description of injuries: Called to room pr CNA. Found resident on floor between the two beds in room. Resident stated, "I was dreaming and I fell out of bed." Resident's head next to her bed, feet under roommate's beside table. Roomates bedspread pulled to floor. ... Bed alarm in place and on but not sounding. ..." The facility's "Incident Investigation," completed by EI #3 regarding RI #1's fall of 3/05/2012 documents, "... Narrative of investigation: Resident was found on the floor by staff after she had gotten up out of bed unassisted. Residents alarm did not sound at time of fall but had been sounding earlier during shift, alarm was checked per writer and was sounding but sounding low and alarm box was replaced at this time. ..." On 4/17/2012 at 4:20 pm, EI #10 was interviewed about RI #1's fall at 3:00 pm on 4/15/2012. EI #10 stated he was doing his rounds at the facility and he walked by RI #1's room and caught a glimpse of something, he stated that he took a few steps back. EI #10 stated when he saw RI #1; she was on the floor at the head of her bed. EI #10 stated he was trained not to touch the residents so he called for the nurse. On 4/18/2012 at 12:24 pm, EI #9 was interviewed about the fall at 3:00 pm on 4/15/2012. EI #9 stated she was trying to leave when a CNA stated that RI #1 was on the floor by the head of the bed. EI #9 stated she assessed RI #1, her bed was at the lowest position then they got RI #1 up off of the floor. EI #9 stated the alarm was working when they laid RI #1 down because they had to check it prior to putting her to bed but it did not alarm when RI #1 fell . EI #9 was asked did she check the bed alarm after the fall. EI #9 stated what she did was to get RI #1 up in the chair because she knew it worked. EI #9 was asked what she did with the alarm. EI #9 stated that after they got RI #1 up the alarm started working. EI #9 explained that the alarms would work then stop and they had informed EI #3, the Unit Manager. EI #9 stated she did not know why the alarms did that. EI #9 stated that she did not want to take the alarm off of the bed because it was the weekend. EI #9 states she did not want to leave her without an alarm and the alarm had started working. EI #9 was asked what intervention she put in place. EI #9 stated she got RI #1 up in the chair and brought her to the nurse's station. On 4/18/2012 at 3:00 pm, EI #11 was interviewed about RI #1's fall on 4/15/2012 at 6:30 pm. EI #11 stated she was making her round and as she walked by RI #1's room. EI #11 stated she heard the alarm beeping and when she went to check RI #1 was on the floor. On 4/18/2012 at 12:46 pm, EI #13 was interviewed regarding RI #1's fall on 4/16/2012. EI #13 stated that she was making her second round and she usually started on the far end of the hall, but that night she started at the top. EI #13 stated that she had done the residents across the hall and was doing the resident next to RI #1. EI #13 stated she was going to get help turning a resident when EI #7 came down the hall because she needed to give resident medications and she said she would help. EI #13 stated she asked EI #7 if RI #1 was still in bed and EI #7 stated yes. EI #13 stated after she finished her (EI #13) was going to check another resident and when she looked in RI #1's room she was not in bed. EI #13 stated she asked EI #7 where RI #1 was. EI #7 stated in the bed and EI #13 stated she told her she was not. EI #13 stated EI #7 went to RI #1's room and she apologized to the resident she was with and went also. EI #13 stated RI #1 was on the floor with her head towards the bed and her feet where under the bedside table. EI #13 stated RI #1 stated she was dreaming and fell out of bed. EI #13 was asked if the alarm was sounding. EI #13 stated the alarm was not sounding. EI #13 stated when EI #7 pressed the alarm with her hand the alarm sounded. EI #13 was asked when she checked the alarm. EI #13 stated that when she got to work EI #12 told her that RI #1 had fallen again and she immediately went to check the alarm. EI #13 was asked when she normally checked alarms. EI #13 stated as soon as she gets to work because sometimes mats are not down, alarms are not turned on. EI #13 commented that was how she was trained and she had worked in the nursing home a long time and that was just what she did. EI #13 stated that before she left she heard a student ask was this lady suppose to be on the side of the bed, the alarm was not sounding so the nurse asked EI #13 to get RI #1 up and place her at the nurses' station. EI #13 stated that was what she did before going home. RI #1's "Departmental Notes," dated 4/16/2012 and signed by EI #3 documents, "...Role: Unit Supervisor ... Resident reviewed in idcp meeting at 11 am resident had three falls over the weekend where the resident got up out of bed unassisted and was found on floor by staff. Resident alarm did not sound on two of falls and will educate staff to ensure that alarm is functioning. Resident noted with increased restlessness will notify md (Medical Director) ..." Attached to the incident report of 4/16/2012 was a facility's "CONTINUING EDUCATION RECORD OF ATTENDANCE," dated 4/17/12. In the upper right hand corner of form was "3-11, 11-7". The form had documented next to course "Ensure alarm is working properly" and had 10 staff member's names. On 4/18/2012 at 3:30 pm, EI #3, Station 3 Unit Manager, was interviewed by the surveyor regarding RI #1's falls. EI #3 was asked the reason for RI #1's fall on 4/15/2012. EI #3 stated that RI #1 was laid down and tried to get up. EI #3 was asked what intervention was put in place after the fall. EI #3 stated when she (EI #3) read the alarm did not sound she assumed it was staff and she in-service staff about ensuring the alarm was working properly. EI #3 stated that later she was told that the alarm had malfunctioned so she replaced the (alarm) box and that was on Monday morning (4/16/2012). EI #3 was asked the reason for RI #1's fall on 4/15/2012 at 6:30pm. EI #3 stated that since the falls happened so close together she tied all three falls together. EI #3 stated she talked to RI #1's doctor and since she was trying to get up, CNA's were to watch her more often. This was the intervention for the second fall. EI #3 was asked the reason for the fall on 4/16/12. EI #3 stated RI #1 was dreaming and fell out of bed. EI #3 stated that RI #1 already had a scoop mattress and they started placing her at the nurse's station. On 4/17/2012 at 6:11 pm, RI #1 experienced a sixth fall at the facility. The facility's "Resident Incident Report" for RI #1, completed by EI #14, a facility LPN, documents, "... Writer was walking down hallway when I heard a bump. Writer saw resident lying on a mat by the shower room on her left side with wheelchair lying on top of her. The alarm was not sounding because it was still attached but working properly. Resident stated "I got caught on the mat " The corner of the mat was turned up by the wheel of the resident ' s chair. Resident denies pain. ..." There is no investigatio