Every finding on record at Green Pine Acres Nursing Home

Based on observation, interview and document review the facility failed to ensure medications were secured for 2 of 2 residents (R2, R4) observed unattended on the Transitional Care Unit (TCU). In addition, the facility failed to ensure safe refrigeration temperatures were maintained for 1 of 4 medication refrigerators (TCU Fridge C) reviewed for medication storage. This had the potential to affect residents residing on the TCU. Findings include:Medication Left Unattended:R2's significant change Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had diagnoses including heart disease and diabetes. R2 received daily injections of insulin. R2's medication order report dated 1/28/26, identified Lantus SoloStar subcutaneous solution pen-injector 100 unit/ml (insulin glargine) inject 9 unit subcutaneously in the morning for DMII, order date 1/19/26.R4's admission MDS dated [DATE], identified R4 was cognitively intact and had diagnoses including renal insufficiency, and diabetes. R4 received daily insulin injections. R4's medication order report dated 1/28/26 identified Lantus SoloStar subcutaneous solution pen-injector 100 unit/ml (insulin glargine) inject 10 unit subcutaneously two times a day for DMII, order date 1/22/26.On 1/28/26 at 7:16 a.m., trained medication aide (TMA)-A was standing at a TCU medication cart prepping medication for a resident. The medication cart was against the wall next to the nurse's desk and in the same area as a larger common area used as the dining room. There were two residents seated at different tables in the area and no staff in the visible area near or around the medication cart. There were two labeled insulin Solostar pens on the corner of the medication cart belonging to R2 and R4. TMA-A was standing at the medication cart, facing the wall with her back to the dining area and prepped and picked up supplies to check a resident's blood sugar. TMA-A turned away from the medication cart, walked into the dining area. TMA-A followed the residents across the dining area, into their room and checked the residents' blood sugar. leaving the insulin back to the medication cart unattended. TMA-A was unable to observe the medications while in the resident's room and checking their blood sugar. Directly following the observation TMA-A stated she had set the insulin pens on the medication cart, just left them there and walked away while one other male resident was seated in the dining room. The risk of leaving insulin and/or medications on the cart was that someone else could pick up the medication and use it. TMA-A stated she should not have left the insulin pens unattended on the medication cart.On 1/28/26 at 7:26 a.m., licensed practical nurse, (LPN)-A walked to the medication cart and removed the two insulin pens from the cart. LPN-A stated there were residents that wheeled around the unit without staff assistance and the insulin pens should not have been left unattended on the cart. The risk of leaving medications unattended was that someone else could take the medications.On 1/28/26 at 8:02 a.m., registered nurse (RN)-A stated medications should not be left unattended on medication carts. The risk of leaving medications unattended was someone else picking them up and using them.The facility Medication Storage policy dated 2/22/24, included all drugs would be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) and during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Medication Refrigerator Temps:The TCU fridge temperature log dated Jan/[DATE], identified nine columns and four rows across the page. The form had instructions for the PM shift and NOC shift. They were to check the temperatures each day and document their initials and record the temperature in the box. At the end of the month staff were to place the form in the DON's box. Columns across the top identified a section labeled PM and NOC shift and one column for each day of the week, Monday through Sunday. Rows across the page identified week one through week four, and had two boxes (one for PM shift and one for NOC shift) for staff to document their initials and fridge temp. Instructions typed across the bottom of the page identified if temps were less than 36 degrees or greater than 46 degrees staff were to report to DON and maintenance and to keep the form in the narcotic book to ensure it was not forgotten as it was required. The form identified there were eight temperatures recorded that were less than the recommended 36-degrees along with six missed entries.The TCU medication room observation was completed on 1/28/26 at 8:08 a.m., with registered nurse (RN)-A. There were two unlocked refrigerators - one under the sink cabinet (C) and a smaller fridge on the floor (F). RN-A stated fridge temps are monitored twice daily, once on the evening shift and once on the night shift and staff were to document on the fridge temp log. At the end of the month the logs were sent to the DON. Fridge temps were to be maintained between 36- and 46-degrees Fahrenheit (F) and staff were instructed to contact maintenance if the temps were out of range. RN-A stated during the month of January 2026, there were five entries where fridge C was out of range, and six days and 12 occasions that the log was blank indicating the temp was not checked. Fridge C contained resident medications including Lantus insulin, NovoLog insulin, T-Dap, Prevnar, and COVID vaccines. On 1/28/26 at 9:50 a.m., the director of nursing (DON) stated staff on the units were supposed to check and document the fridge temps twice daily. At the end of the month the forms were sent to the DON. The DON stated she did not review the forms and assumed the unit managers reviewed the logs before sending them to her (the DON). The nursing staff were instructed to contact maintenance, as well as herself, if there were issues with the fridges. The DON stated she was unaware of any out-of-range temps for the TCU fridges for the month of January. DON reviewed the January 2026 fridge temp log and stated 5 entries were less than the recommended 36 degrees F and six days were left blank.On 1/28/26 at 11:49 a.m., the pharmacist stated the facility should check their fridge temps according to their policy and if the temps fell out of range, they should follow their policy as well as contact the pharmacist for review of medication recommendations regarding low/high temp exposure. The pharmacist stated he did not have any immediate concerns regarding the low temps although he would have to reach out to the facility and review an itemized list of the medications in the fridge and the recommendations to be sure.On 1/28/26 at 12:47 p.m., the DON stated RN-A had contacted the pharmacy earlier and discussed each of the medications in fridge C. The pharmacist recommended the following medications be destroyed and replaced:One Lantus Solostar penOne Novolog Solostar penOne Prevnar injectionOne T-Dap vaccineOne COVID vaccineThe facility Medication Fridge Policy dated 9/12/19 identified the medication fridge should be checked twice daily and the goal range was between 36- and 46-degrees F. Anything outside of range should be reported to the DON and maintenance.

Based on observation, interview and document review, the facility failed to follow their policies, and or acceptable standards of practice, to ensure medication administration accuracy for 2 of 2 residents (R23, R66) reviewed for narcotic count accuracy. Findings include:R23's comprehensive Minimum Data Set (MDS) dated [DATE], identified R23 was cognitively aware and had diagnoses that included breast cancer, heart failure, and chronic obstructive pulmonary disease (COPD). R23 was receiving hospice services. R23's physician order dated 12/5/25, identified lorazepam oral tablet 0.5 milligram (mg). Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation for 14 Days. Call Hospice prior to administering the first dose - must chart non-pharmacological interventions attempted.R23's Medication Administration Record dated December 2025, identified lorazepam oral tablet 0.5 milligram (mg). Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation for 14 Days. Call Hospice prior to administering the first dose - must chart non-pharmacological interventions attempted. However, the record did not identify R23 ever received the medication.The undated black, bound Individual Narcotic Record identified on page 97 R23's lorazepam was received on 12/5/25 with an RX number (a unique identifier assigned to a prescription) of 4004867 518 with five 0.5 milligram (mg) tablets received. On 12/29/25, a handwritten entry identified two tablets were administered to R23 by trained medication aide (TMA)-B, however, this line was scratched out and underneath the quantity remaining identified 5 along with licensed practical nurse (LPN)-B's signature. A sticky paper was attached to the page with a handwritten note that stated, 5 different tabs/code 1/2 tabs are 0.5 mg [NAME] RN.During an observation on 1/26/26 at 6:11 p.m., R23's lorazepam bottle held three 0.5 mg tablets of lorazepam and a 1 mg tablet of lorazepam broken into two pieces totaling five 0.5 mg tablets.R66's undated admission Record, identified R66 was admitted to the facility on [DATE] and had diagnosis that included cancer and palliative care.R66's Order Summary Report dated 12/12/25, identified lorazepam oral tablet 1 mg tablets. Give 1 tablet by mouth four times a day for anxiety/shortness of breath (SOB). - every 6 hours around the clock (ATC).R66's Medication Administration Record dated December 2025, identified R66 received lorazepam 1 mg on 12/29/25 at 7:00 p.m.The undated black, bound Individual Narcotic Record identified on page 126 R66's lorazepam was received on 1211/25 with an RX number (a unique identifier assigned to a prescription) of 4005034. On 12/29/25 at 6:48 p.m., a handwritten entry identified 1 tablet were administered to R66 by TMA-B.During an interview on 1/26/26 at 7:11 p.m., LPN-B stated she was aware of a discrepancy with R66 and R23's lorazepam narcotic count, but it had been a long time since that happened and didn't recall the date nor what occurred. LPN-B did recall replacing the tablets in R23's lorazepam prescription bottle because they're the same strength even though it was a 1 mg tablet broken in half. LPN-B stated no staff were directed to not take from one medication bottle and put in another, but R23's medication was mistakenly used for R66. So, they were just replaced. LPN-B stated TMA-B had mistakenly used R23's medication for R66 and LPN-B only fixed it. During an interview on 1/26/26 at 7:14 p.m., TMA-B stated on 12/29/25 he mistakenly administered R23's lorazepam tablets to R66. TMA-B stated he realized his error as soon as he documented the administration on page 97 under R23. TMA-B stated he immediately brought the error to LPN-B. TMA-B nor LPN-B completed a medication error report nor reported the error to administration.During an interview on 1/26/26 at 7:27 p.m., LPN-B stated the incident was a medication error because the medication was administered to the wrong resident and the tablet dose did not match the medication order. LPN-B stated TMA-B should have realized it was the incorrect medication when comparing the bottle to the medication order. LPN-B stated she did not inform administration because LPN-B replaced the medication in the bottle and thought it wasn't a big deal. During a telephone interview on 1/27/26 at 9:34 a.m., the pharmacist stated he was unaware of a medication error involving R23 and R66's lorazepam and stated the facility must complete a medication error report. Stated staff were not allowed to borrow medications between residents for medication safety and for tracking of medications. Education would be provided to the staff to ensure all staff were aware of the process and what to do in the future. During an interview on 1/28/26 at 11:39 a.m., registered nurse (RN)-A stated when a discrepancy or incorrect medication was used in error a medication error report was completed. The report was a paper form and once completed was given to RN-A. RN-A would do an investigation of what happened and then provide education to the staff involved. After that, the form would be given to the director of nursing (DON). RN-B stated she was unaware of error when R23's lorazepam was used until 1/27/25. Afterwards, the pharmacist was contacted to get his recommendations. RN-A stated LPN-B completed a medication error report on 1/27/25. Staff had been told not to borrow medications from residents to use for another and to notify pharmacy, the RN in charge, and the resident's provider.During an interview on 1/28/26 at 11:55 a.m., the DON stated she was notified of the medication error on 12/27/25 when the person involved came forward and wrote herself up. When a staff member makes a medication error, they complete a medication error report and give it to the unit manager or the DON. Then, either the unit manager or the DON, provide one-to-one education to the staff member and then do an audit to ensure further education did not need to occur. The DON stated when LPN-B explained the situation, LPN-B didn't realize replacing the medication was wrong. LPN-B thought it was an easy fix, and she had been educated on how the process should have been. Normally, the DON would expect staff to report it as a medication error. The DON stated there were a couple reasons why staff could not borrow from one resident's medications for another resident. First, the pharmacist dispenses medications and there is a process to ensure medications were correct and it was best practice in having more than one person involved to ensure safety. Additionally, there was the financial piece as well because the medication belongs to the resident. Further, it was best practice to be aware of the error because LPN-B had never incurred a situation like that and just didn't realize it was an error. All staff could learn from that. During an interview on 1/28/26 at 2:21 p.m., the administrator stated she expected staff to inform the DON of all medication errors when identified and to follow facility policy. The facility policy Medication Administration revised 5/22/24, identified the six {6) rights of medication administration should be followed with each medication or treatment. These include right resident, medication, dose, time, route, and documentation.A facility policy regarding medication error was requested but not received.

Based on observation, interview and document review, the facility failed to ensure the use of motion sensor pager devices were assessed for range upon implementation and when identified the sensor did not alert staff to movement as intended for 1 of 2 residents (R60) reviewed for falls. Findings include: The undated 433 CMU Manufacturer Instructions identified the range of the monitors were 150 to 300 feet; however, environmental factors such as concrete or brick walls and heavy electrical equipment could affect the range. The systems relied on technology which was subject to physical and environmental considerations transmitter would not be 100% accurate if it was out of range. It was the end users responsibility to make sure the product was used correctly and within range. The device was intended as an adjunct to good care giving practices and not a substitute for proper staffing and management practices. It was commended all staff received proper training and the device tested daily. The device was not meant to replace direct patient supervision, adequate staff training and testing of the system before each use. R60's quarterly Minimum Data Set (MDS) dated [DATE], identified R60 had moderately impaired cognition. R60 required moderate assistance with dressing, grooming and transfers and maximum assistance with toileting hygiene. R60 was frequently incontinent of bowel and bladder. Diagnoses included dementia, heart disease, and anxiety. R60's Fall Risk assessment dated [DATE], identified R60 had a history of multiple falls within the last six months. R60 required assistance of one to transfer but would still self-transfer which often resulted in her falls. R60 had a sensor pad on her bed and a sensor boxy in the bathroom doorway to alert staff. The assessment lacked any evidence the alarm box ranges were individually assessed for distance to ensure the alarm functioned as intended, to alert staff to R60's movement. R60's medical record lacked any assessment for alarm box ranges in relation to the sensor to ensure the alarm functioned as intended, to alert staff to R60's movement. R60's care plan revised 12/24/24, identified R60's need for assistance with activities of daily living (ADLs) and R60's mobility fluctuated due to cognition and/or fatigue. A goal was identified to avoid complications with mobility such as falls, injuries or decline. An intervention included a sensor box on R60's bathroom door and directed staff to carry the alarm box (that would alert if R60 attempted to enter the bathroom). The care plan did not identify any how far staff could be with the alarm box to ensure the proper functioning of the alarm. R60's Fall Investigation Worksheet dated 8/26/24, identified R60 had an unwitnessed fall and was found on the floor in the bathroom. The bathroom alarm was in place and trained medication assistant (TMA)-A had the alarm box in her pocket. Nursing assistant (NA)-A had taken R60 to her room following supper in the dining room and secured the call light with in R60's reach. R60 had removed the call light and attempted to self transfer to the bathroom and fell . TMA-A reported the alarm box for the bathroom motion sensor had not sounded an alert. The root cause of the fall was determined to be the need to toilet and the intervention to assist R60 to the bathroom after supper was implemented. Batteries were changed to sensor box and alarm. The investigation worksheet lacked evidence an investigation was conducted to determine why the bathroom sensor alarm had failed to alert when R60 entered the bathroom. R60's CNA Fall Worksheet dated 12/22/24, identified R60 had an unwitnessed fall and was found on the floor in the bathroom. R60 stated she had been trying to go to the bathroom. Fuzzy socks and slippers were determined to have contributed to the fall. The worksheet lacked any further investigation into whether the alarms sounded as intended, and if not, any investigation into why the alarm did not sound as intended. During interview on 3/17/24, at 7:24 p.m. NA-B stated R60 would try to take herself to the bathroom a lot. R60 had a motion sensor in her bathroom door and they could usually catch her before she fully got out of her wheel chair. It had not alarmed when she fell in the bathroom on 12/22/24. When interviewed on 3/18/25, at 8:31 a.m. NA-C stated R60 had a sensor on her bed and bathroom door to alert staff when she moved. An aide would be assigned to keep the box in their pocket and it would alarm by playing music or a noise loudly if R60 entered the bathroom. If the aide went on break, they would hand it off to someone else. R60 would try to go to bed or to the bathroom herself and she fell a lot because of that. The alarm was not working when she fell on [DATE]. During interview on 3/18/25, at 9:05 a.m. registered nurse (RN)-A stated R60 did have falls due when trying to self transfer. R60 had a motion sensor on her bathroom door and a nursing assistant carried the receiver box in their pocket. The box would chime or made a musical sound when R60 entered her bathroom. The aide that had the alarm box on 12/22/24, was in the dining room and the alarm did not sound. RN-A stated the aide was not in range for the alarm to sound. During interview on 3/18/25, at 10:06 a.m. NA-D stated she was not aware if there was any range for the alarm and was not aware of it not working. During interview on 3/18/25, at 10:09 a.m. TMA-C stated she was wearing the motion sensor box for a resident this morning. She did not think there was a range where the alarm would not work. If they were to go on break they handed the alarm box to someone else and was not aware of it not working. During interview on 3/18/24, at 10:23 a.m. NA-E stated the motion sensor alarm had always worked for her when she had it and was not aware of any ranges. During interview on 3/18/25, at 11:07 a.m. TMA-D stated she had the alarm on 12/22/24, when R60 fell . TMA-D stated she had been wheeling another resident into the dining room and setting her breakfast up when she received a call over the walkie asking who had R60's alarm. TMA-D ran to R60's room but she had already fallen. The alarm had not sounded at all. TMA-D had been told she was out of range of the alarm for it to sound. That was the first time she had ever heard there was a range to the alarm box. When she had started down to R60's room in response to the call on the walkie that she had fallen, the alarm started blaring loudly, so she did not feel the batteries were low. A joint interview was conducted on 3/18/25, at 11:31 a.m. with the director of nursing (DON) and the administrator. The DON stated she had gotten a call at home regarding the fall and was told the alarm was working and the aide had it on their person. The aide was in the kitchen and the DON thought there was a distance limit on the alarms but was not sure what the footage was. The alarm did sound when the aide entered the hallway, so may have been a delay of a couple of seconds. The DON did not know the range of the motion sensors to the alarm box and looked it up on the website, which indicated the range was 300 feet. Both the DON and the administrator stated they had never tested the range of the motion sensor alarm and thought it would be difficult as the nursing assistants moved through out the halls. The alarm was not investigated or tested following R60's fall. On 3/18/25, at 12:20 p.m. the DON placed the motion sensor alarm in R60's former room and called to the nursing assistant on the walkie who had the alarm box. The NA stated she was in the dining room assisting a resident. The DON activated the alarm in R60's room and the NA reported the alarm box did not sound. The DON stated there must be to many walls between the alarm box and motion sensor. The administrator stated the alarm did work and the care plan was followed but it was out of range. During telephone interview on 3/18/25, at 1:09 p.m. the manufacturer of the Wireless Motion Sensor Smart Caregiver Fall Prevention and Anti-wandering Alarm help desk, (MHD)-C stated the alarms were used in quite a few nursing homes. MHD-C stated the determining factor of the range of the sensor was what was between the sensor and the alarm box. The sensor used radio waves and concrete, brick, metal, electrical would all effect the range. The typical range was 150 to 300 feet, but it would depend on what was directly in between the sensor and the alarm box. The absolute maximum distance was 300 feet and that would be if the alarm box and the sensor were in direct line of site. The only way to know the range of how far an alarm will reach from where you placed the sensor was to test it. It was not difficult to test the range. The motion sensor would be placed to where you wanted it and then someone with the alarm box would go a distance away and keep moving away a distance until the alarm box no longer picked up the sensor. A follow up joint interview was conducted on 3/19/25, at 3:54 p.m. with the DON and administrator. The DON stated she did not work at the facility at the time of R60's first fall and could not say what type of investigation was done to determine the cause of the fall or if the motion sensor was investigated. The DON did not know what assessment was completed to determine the motion sensor alarm was appropriate. It would be hard to determine the range of the sensor, it would be different for each resident. The administrator stated the staff were aware the motion sensors were not a fool proof thing and knew there were limitations to the alarms. The sensors were effective and they could not possibly identify where/if there were dead spots for each resident, as the ranges could change. The facility policy Resident Alarms dated 2/6/25, identified the facility would establish and utilize a systematic approach for the safe and appropriate use of resident alarms, including efforts to identify risk, evaluate and analyze risk, implement interventions to reduce risk and monitor for effectiveness of the interventions and modifying interventions when necessary. When alarms were utilized, additional monitoring would be provided, including but not limited to verifying the alarms were used in accordance to the care plan, working properly and monitoring for adverse consequences. Each resident would be assessed for fall and elopement risk on admission and periodically thereafter. Medical symptoms would be identified and documented in the medical record. Information would come from the medical history, physical exam or individual observation. When alarms were in use or under consideration, risks of adverse consequences related to alarms would be identified.

Based on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect range of motion status for 2 of 17 residents (R2, R29) who were in the sample. Findings include: R2: R2's Physical Therapy Evaluation and Plan of Treatment dated 11/19/24, identified R2 impaired ROM in both upper and lower extremities. R2's admission Minimum Data Set (MDS) dated [DATE], R2's functional range of motion (ROM) identified R2 had no limitations of range of motion in either upper or lower extremities. Diagnoses included multiple sclerosis and quadriplegia. R2's Mobility Assessment-V2 dated 2/26/25, identified R2 had contractures present and was unable to extend his left elbow past 90 degrees. Bilateral knees and ankles had poor ROM. R2's quarterly MDS dated [DATE], R2 was dependent with all areas of activities of daily living, required a mechanical lift to transfer and was unable to ambulate. R2's functional RO) identified R2 had no limitations of range of motion in neither upper or lower extremities. Diagnoses included multiple sclerosis and quadriplegia. R2's care plan revised 2/27/25, identified R2 required a restorative nursing program. R2 had contractures to their lift elbow extension, right elbow flexion, and tight overall tone and was at risk for developing additional contractures. Staff were directed to complete passive ROM alternating between upper and lower extremities every other time. During observation on 3/19/25, at 10:43 a.m. R2 was lying on his right side while staff performed a dressing change to his left buttock area. R2 had difficulty moving his upper extremities and was unable to move his lower extremities without assistance. R2's fingers had poor dexterity and limited ROM due to stiffness and contractures. R29: R29's care plan revised 12/5/23, identified R29 had a decline in mobility with limited ROM in right ankle. R29 required a restorative nursing program due to a risk for contractures. Staff were directed to complete active ROM exercises to her lower and upper extremities and transfers to maintain strength. R29's Mobility Assessment-V2 dated 12/27/24, identified R29 had limited ROM to her right shoulder. R29's right elbow had moderate ROM and R29 had right ankle inversion with moderate ROM. R29's quarterly MDS dated [DATE], identified R29 required partial to maximum assistance with most ADL's and was dependent with transfers and mobility. R29's functional ROM identified R29 had no limitations of range of motion in either upper or lower extremities. Diagnoses included cerebral infarction, polyosteoarthritis, and epileptic spasm. R29's Occupational Therapy Evaluation and Plan of Treatment dated 4/17/24, identified R29 had impaired ROM in her right upper extremity. During observation on 3/17/25 at 1:23 p.m. R29 was observed seated in a wheelchair in her room. R29 was leaning heavily to right side and her legs and feet were not positioned fully on the wheelchair foot rests. R29 was unable to lift her arms or her legs to correct her position and rang for staff assistance. During interview on 3/19/25, at 2:24 p.m. licensed practical nurse (LPN)-A stated she completed the MDS assessments for all the resident's residing in the facility. LPN-A reviewed the resident's mobility assessment to determine each resident's upper and lower extremity ROM. LPN-A thought she may have been reading the MDS question related to a resident's ROM incorrectly. She coded the resident with impaired ROM only if there was a potential for injury with movement. Now in reviewing the MDS ROM section she could see R2 and R29's MDS were coded incorrectly. When interviewed on 3/19/25, at 3:12 p.m. the director of nursing (DON) stated she did not agree R2 and R29 had full ROM of all their extremities. If both therapy and the mobility assessments identified a resident had impaired ROM in any of their extremities, then the MDS should reflect that. It was important to have the ROM limitations correctly identified on the MDS to account for the resident need for assistance with ADLs. The facility policy MDS 3.0 Policy Procedure dated 5/1/24, identified the facility would complete a comprehensive assessment of the resident needs. The assessment would include a resident's physical functional status, ability to perform activities of daily living, and the resident's need for staff assistance and assistive devices or equipment to maintain or improve functional abilities. The MDS staff would encode accurate information into the MDS. The Centers for Medicare & Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, identified a purpose to offer clear guidance on how to use (i.e., code) the RAI which was divided in multiple sections. The manual outlined, Section GG: Functional Abilities, which directed an intent to determine whether functional limitation in range of motion (ROM) interfered with the resident's activities of daily living or placed them at risk of injury. The manual outlined the item coded for the presence or absence of functional limitation related to ROM, and thorough assessment ought to be comprehensive and follow standards of practice for evaluating ROM impairment. Coding instructions included to code 0 if resident had full functional range of motion on the right and left side of upper/lower extremities, code 1, impairment on one side if resident had an upper- and/or lower-extremity impairment on one side that interfered with daily functioning or placed the resident at risk of injury, and code 2, impairment on both sides, if resident had an upper- and/or lower_extremity impairment on both sides that interfered with daily functioning or placed the resident at risk of injury.

Based on interview and document review the facility failed to implement immediate protection of residents (delayed three days) following an allegation of staff to resident sexual abuse for 1 of 3 residents reviewed for abuse. Findings include: R1 Admission Record identified diagnosis that included Alzheimer's disease, depression, anxiety and dementia. A report to the state agency (SA) dated 8/29/24, indicated on 8/26/24, nursing assistant (NA)-A report to registered nurse (RN)-A while she was assisting R1 to get dressed, her bra was up over her breasts and NA-B walked into the room and stated oh, boobies, then walked over to R1 and flicked her breast up. Facility Investigation submitted to the SA on 9/4/24, indicated NA-B had walked toward R1, took the back of her hand and lifted R1's breast and stated something like, Boing and let R1's breast fall. The report indicated when NA-A asked NA-B why she had one that, NA-B told her, Oh, I just seen a boob nonchalantly. The investigation indicated NA-B denied remembering what she had said, denied intending to humiliate R1 and denied that her intentions had been sexual in nature. During interview on 9/6/24 at 11:22 a.m., NA-A stated on 8/26/24, she and NA-B were assisting R1. NA-A stated R1's shirt was pulled up over her breasts as they were waiting for the trained medication aide to come in and apply powder under her breasts. NA-A stated NA-B stepped forward and with the back of her hand, lifted up R1's breast and made a sound effect. NA-A said when she asked NA-B why she did that, NA-B acted like it was no big deal. NA-A stated she felt like NA-B thought it was funny. NA-A said she felt it was very inappropriate and said it should not have happened. NA-A stated she reported the incident to RN-B shortly after the incident occurred. During interview on 9/6/24 at 1:40 p.m., the administrator stated she had been notified of the incident on 8/29/24, three days after the incident occurred. The administrator said NA-B had been suspended on 8/29/24, and said NA-B had worked between 8/26/24, and 8/29/24 when she had been suspended. Facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 6/10/19, identified sexual abuse as any non-consensual sexual contact of any type with a resident. The policy indicated when suspected abuse was identified, safety measures would be implemented to ensure the safety of the suspected vulnerable adult and other residents. Such safety measure may include moving a resident to another room or floor, providing staff supervision of resident, as needed, and separating the suspected perpetrator and residents which may include placing an employee on administrative leave until the investigation was completed.

Based on interview and document review the facility failed to timely report an allegation of staff to resident abuse to the facility administrator and the state agency for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's Admission Record identified diagnosis that included Alzheimer's disease, depression, anxiety and dementia. A report to the state agency (SA) dated 8/29/24, indicated on 8/26/24, nursing assistant (NA)-A report to registered nurse (RN)-A while she was assisting R1 to get dressed, her bra was up over her breasts and NA-B walked into the room and stated oh, boobies, then walked over to R1 and flicked her breast up. During interview on 9/6/24 at 11:22 a.m., NA-A stated on 8/26/24, she and NA-B were assisting R1. NA-A stated R1's shirt was pulled up over her breasts as they were waiting for the trained medication aide to come in and apply powder under her breasts. NA-A stated NA-B stepped forward and with the back of her hand, lifted up R1's breast and made a sound effect. NA-A said when she asked NA-B why she did that, NA-B acted like it was no big deal. NA-A stated she felt like NA-B thought it was funny. NA-A said she felt it was very inappropriate and said it should not have happened. NA-A states she reported the incident to RN-B shortly after the incident occurred. During interview on 9/6/24 at 11:33 a.m., RN-B stated when NA-A reported the incident to her, she was rounding with the nurse practitioner so she reported the incident to RN-A. RN-B said NA-A reported to her while performing cares for R1, NA-B flopped her breast, not in a nice way, and made a comment about boobies and was saying boob, boob. RN-B stated she had told the other unit manager (RN)-A, but had not reported the incident to the director of nursing or the administrator. RN-B stated she was aware the timeframe for reporting allegations of abuse was two hours. During interview on 9/6/24 at 11:48 a.m., the administrator stated she had been made aware of the incident by RN-A on 8/29/24, three days after the incident occurred. During a subsequent interview at 1:40 p.m., the administrator said when the incident was reported to her she asked RN-A and RN-B why they had not reported the incident when it happened. The administrator said RN-A said she hadn't thought the incident was anything until NA-A brought it up three days later. The administrator stated staff education had not been implemented following the late reporting. Facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 6/10/19, indicated suspected abuse shall be reported to the administrator and SA no later than two hours after forming the suspicion of abuse. The policy identified sexual abuse as non-consensual sexual conduct of any type with a resident.

Based on interview and document review, the facility failed to ensure a significant change in status assessment was completed for 1 of 2 residents (R56) reviewed for nutrition Findings include: R56's admission MDS, dated [DATE], identified R56 had moderate cognitive impairment, required substantial to maximum assistance with toilet hygiene and shower, partial to moderate assistance to dress lower body, turn and reposition in bed and transfer. R56 was frequently incontinent of bladder, however was continent of bowel. R56's quarterly MDS, dated [DATE], identified R56 had severe cognitive impairment, was dependent with toilet hygiene and to dress his lower body. R56 also required substantial to maximum assistance with dressing upper body, bathing, turning and repositioning in bed and transfer. R56 was frequently incontinent of both bowel and bladder. All of which identified a decline with R56's incontinence pattern as well as decline in physical functioning for ADL's from the MDS completed on 11/24/23. R56's weight and vitals summary identified R56's weight on admission was 174 pounds. On 2/21/24, R56's recorded weight was 158 pounds. This was an unidentified significant weight loss of 9.2%. The medical record lacked evidence a significant change in status MDS or a progress note identifying why a significant change in status was not required at the time. When interviewed on 4/17/24, at 9:31 a.m. registered nurse (RN)-B stated she completed the MDS after reviewing with the medical record and discussing resident's condition and care with the unit managers. Hospice care was discussed with R56's family, however, the family was not ready to initiate hospice services yet. RN-B knew the unit manager made a lot of changes with care to R56's care plan when the quarterly MDS period was being completed; and that should have prompted a significant change MDS assessment. RN-B stated R56 was requiring increase assistance with all of his ADL's but had not connected the newly coded dependencies with R56's decline in ADL functioning was a significant change, as she was not used to new MDS format and found it hard to compare to R56's previous MDS's. It would be important to complete significant change MDS assessments to ensure accurate care planning and family discussion regarding the resident changes. A significant change MDS should have been completed when R56 had multiple changes regarding cognition, ADL's and nutrition. During interview on 4/17/24, at 3:26 p.m. the director of nursing (DON) stated she was aware R56 had weight loss but had not been aware R56 had a decline in ADL function as well. It would be important to complete a significant change MDS to update the care plan as well as for financial reasons. The undated facility policy MDS 3.0 Policy Procedure identified the facility would conduct initial and periodic comprehensive, accurate, standardized reproducible assessments of each resident's functional capacity as warranted in the most updated version of the MDS 3.0 RAI Minnesota Manual. The facility would obtain ongoing assessment information necessary to develop a care plan, to provide appropriate care and services for each resident, and to modify the care plan and care/services based on the resident's status. The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2023, indicated a significant change in status assessment (SCSA) was required when various criteria were met. The manual identified a significant change was a decline in a resident's status that would not normally resolve itself without intervention by staff, impacted more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. A SCSA would be appropriate if there were two or more areas or decline such as emergence of unplanned weight loss, change in resident's incontinence pattern or any decline in activities of daily living (ADL) physical functioning area where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, or dependent.

Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 5 of 5 residents (R26, R30, R32, R34, R38) reviewed for immunizations. Findings include: R26's Admission Record dated 7/26/23, identified an admitted [DATE], and was [AGE] years old. R26 had diagnoses that included Parkinson's disease and lewy body dementia. R26's Minnesota Immunization Information Connection (MIIC) dated 7/26/23, identified R26 received the pneumococcal polysaccharide vaccine (PPSV23) on 3/21/15, and pneumococcal conjugate vaccine (Prevnar 13) on 3/23/18. R26's EHR did not include evidence R26 or R26's representative received education regarding pneumococcal vaccine booster and there was no indication R26 was offered the pneumococcal vaccine per CDC guidance. R30's Admission Record dated 7/26/23, identified an admitted [DATE], and R30 was [AGE] years old. R30 had diagnoses that included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and end stage kidney disease with dependence on renal dialysis. R30's MIIC dated 7/26/23, identified R30 received the PPSV23 on 4/10/08 and 9/13/08. R30's Immunization Report dated 7/26/23, identified R30 received the Prevnar 13 on 8/22/17. R30's EHR did not include evidence R30 or R30's representative received education regarding pneumococcal vaccine booster and there was no indication R30 was offered the pneumococcal vaccine per CDC guidance. R32's Admission Record dated 7/26/23, identified an admitted [DATE], and R32 was [AGE] years old. R32 had diagnoses that included Alzheimer's disease, type 2 Diabetes, and atrial fibrillation. R32's MIIC dated 7/26/23, identified R32 received the PPSV23 on 12/19/07 and the Prevnar 13 on 3/6/18. R32's EHR did not include evidence R32 or R32's representative received education regarding pneumococcal vaccine booster and there was no indication R32 was offered the pneumococcal vaccine per CDC guidance. R34's Admission Record dated 7/26/23, identified an admitted [DATE] and R34 was [AGE] years old. R34 had diagnoses that included Alzheimer's disease. R34's MIIC dated 7/26/23, identified R34 not received either the PPSV23 and/or the Prevnar 13. R34's [NAME] Connections form dated 1/17/20, identified Pneumococcal Conjugate (Prevnar 13) would be offered that year. The form further identified a flyer from the CDC concerning symptoms of pneumococcal conjugate, who should be immunized and possible side effects of getting the vaccine. The form directed the resident or responsible party to read the flyer, sign the consent and return it as soon as possible. There was an x mark next to I do not want to receive the Pneumococcal Conjugate Vaccine. The form was signed by the responsible party and dated 1/17/20. However, the form did not identify what education regarding the pneumococcal vaccine was offered nor did the form identify that R34 was offered the all the pneumococcal vaccine(s) per CDC guidance. R38's Admission Record dated 7/26/23, identified an admitted [DATE] and R38 was [AGE] years old. R38 had diagnoses that included anoxic brain damage, history of heart attack, CHF, hypertension, seizures, and aphasia. R38's nursing progress note dated 11/19/20 at 2:31 p.m., identified R38 was underage for pneumococcal vaccines. Previous nursing facility reported family had declined offers for vaccines, but the facility would offer again. The progress note did not identify documentation that R38 or R38's representative received education regarding pneumococcal vaccine booster and there was no indication R38 was offered the pneumococcal vaccine per CDC guidance. The Centers for Disease Control and Prevention (CDC) Vaccines and Preventable Diseases reviewed 2/13/23, identified, the CDC recommended pneumococcal vaccination for adults 19 through [AGE] years old who have certain chronic medical conditions or other risk factors. These risk factors included chronic heart disease, including congestive heart failure and cardiomyopathies. During interview on 7/26/23 at 12:54 p.m., registered nurse (RN)-A stated she was the facility infection preventionist. She stated she did not review resident's immunization history, nor did she offer vaccines to resident because that was the role of the admission nurse. During an interview on 7/26/23 at 1:14 p.m., the director of nursing (DON) stated the admission nurse did review resident immunizations upon admission and the unit managers would follow up afterwards such as during the influenza season. The DON was aware there were changes to the CDC guidance regarding pneumococcal vaccines but could not recall the specifics nor had the facility reviewed resident to determine which residents were eligible for the vaccine. The DON stated they were in the process of transitioning the role to a new IP. The resident immunizations would need to be reviewed and addressed timely to prevent the spread of communicable disease. The facility provided Vaccine Information Statement (VIS) Pneumococcal Polysaccharide Vaccine dated 4/24/15 and Pneumococcal Conjugate Vaccine (PCV13) dated 11/5/15, identified education regarding the need for PPSV23 and Prevnar 13. However, the VIS did not provide education regarding new recommended guidance to receive a PCV20. The facility policy revised 6/1/23, identified the facility would offer residents, staff, and volunteer workers immunizations against pneumococcal disease in accordance with current CDC guidelines and recommendations. The policy further identified each resident would be assessed for pneumococcal immunization upon admission. Self-report of immunization would be accepted. Any additional efforts to obtain information would be documented, including efforts to determine date of immunization or type of vaccine received. Prior to offering the pneumococcal immunization, each resident or resident's representative would receive education regarding the benefits and potential side effects of the immunization. The individual receiving the immunization, or the resident representative, would be provided a copy of the CDC's current vaccine information statement relative to that vaccine. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV) offered would depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. However, the policy did not address review of immunization records for residents already residing in the facility when new, changed and/or additional vaccine booster guidance was recommended.

Based on interview and document review, the facility failed to ensure medications were administered without significant error for 1 of 1 resident (R1) who received the incorrect dose of diuretic (fluid reducing) medication for 19 days. This deficient practice caused harm for R1 who experienced increased [CONDITION(S)], shortness of breath and required treatment at the emergency room (ER) and received intravenous (IV) medication administration of [MEDICATION(S)]. The immediate jeopardy (IJ) began on 8/12/20, when facility staff incorrectly administered R1's dose of [MEDICATION(S)] 20 milligrams (mg) and continued to administer the incorrect dose (10 mg) until 9/1/20, when the error was identified. On 8/31/20, R1 was sent to the emergency room , administered IV [MEDICATION(S)] and diagnosed with [CONDITION(S)] and fluid overload. The administrator and the director of nursing (DON) were notified of the immediate jeopardy at 4:05 p.m. on 9/14/20. The immediate jeopardy was removed on 9/16/20, at 12:00 p.m., but noncompliance remained at the lower scope and severity level of G, which indicated actual harm that is not immediate jeopardy. Findings include: A facility Nursing Home Incident Reporting form submitted by the facility on 9/1/20, at 4:47 p.m., indicated an order was received by the facility on 8/11/20 to increase R1's [MEDICATION(S)] from 10 mg daily to 20 mg daily, to start on 8/12/20. R1 did not receive the increased dose of 20 mg daily as ordered, which was discovered by the facility on 9/1/20, when the cassette in R1's medication cart was discovered to have 10 mg tablets, not the 20 mg tablets as ordered. The cassette was labeled to read [MEDICATION(S)] 20 mg, take one-half tab by mouth daily. On 8/31/20, R1 was sent to the emergency room (ER) with increase in [MEDICATION(S)] ordered, for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 had mild impaired cognition and received anti depressant medication on a daily basis. R1's MDS incorrectly indicated R1 did not receive diuretic medication in the 7 day look back period. R1's MDS also indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Order Summary Report dated 8/6/20, included oxygen at 3 liters (L) via nasal cannula every shift for [CONDITION(S)] related to CHF with start date of 4/30/20, and [MEDICATION(S)] 10 mg by mouth in the morning for CHF with start date of 4/8/20. R1's Physician Telephone order, dated 8/11/20, at 10:45 a.m. ordered an increase [MEDICATION(S)] to 20 mg due to [CONDITION(S)] and CHF. However, R1's progress notes did not identify R1 was having any symptoms at that time. R1's ER (emergency room ) report dated 8/31/20, indicated R1 presented with abdominal distention and diarrhea. R1's exam revealed evidence of CHF with bilateral rales and peripheral [CONDITION(S)]. R1's abdomen was distended but non-tender. Chest X-ray showed pleural effusion and cephalization (refers to the redistribution of visible pulmonary vessels into the upper lung fields as pulmonary vascular volume and pressures increase) indicating pulmonary congestion. R1's abdominal CT scan showed ascites (fluid in the abdomen) and signs of [CONDITION(S)] (liver disease). R1 was treated with IV [MEDICATION(S)] 40 mg. R1's family member declined hospitalization , and R1 returned to the nursing home with [MEDICATION(S)] 40 mg by mouth daily with supplemental potassium daily. R1's discharge patient information form dated 8/31/20, indicated R1 was seen in the emergency room for CHF and [CONDITION(S)]. Review of R1's progress notes (PN) from 8/10/20 through 9/11/20, revealed the following information: -8/11/20 at 11:04 a.m. indicated an order was received to increase R1's [MEDICATION(S)] dose to 20 mg every day for [CONDITION(S)] and CHF. However, the notes lacked documentation of any symptoms R1 was experiencing at that time. -8/13/20, noted to have 1+ pitting [CONDITION(S)] and R1 stated she did have gout. -8/19/20, complained of chest pain and shortness of breath and per staff report seemed off. After 5 minutes, on reassessment, R1'S symptoms had improved. -8/21/20, turning on her call light frequently and calling office and family members. R1 was very upset and staff was unable to answer her questions. -8/21/20, another note indicated R1 appeared to be having discomfort and shortness of breath. R1 was agitated and anxious. R1's oxygen saturation registered at 84% (normal range-95-100%) with oxygen administered at 3L per nasal cannula and she complained of acid reflux. Staff repositioned R1 and spoke with her regarding her concerns. Staff administered Maalox (an antacid medication) and R1 appeared to relax and interventions appeared effective. -8/23/20, abdomen seemed firm and distended. R1's bowel sounds were active and R1 had a documented bowel movement every day. -8/23/20, another note indicated R1 would turn on the call light when staff left the room and rang the call light frequently. R1 complained of not being able to breath. R1's oxygen saturation registered 93% with oxygen on at 3L per nasal cannula. -8/28/20, continued to have a distended abdomen. Lab work ordered for liver function. R1 was documented to have 2+ bilateral lower extremity [CONDITION(S)]. -8/29/20, liver function lab work was within normal limits. -8/31/20, R1 was noted to be pale and lethargic and had five loose stools. R1's abdomen was extended and firm. Bowel sounds were hyperactive. R1 had 3+ [CONDITION(S)] in both lower extremities. Lung sounds were clear and oxygen saturation was 89% with oxygen on at 3L/minute per nasal cannula. R1 was sent to the hospital for an X-ray. -8/31/20, a later note written by the director of nursing (DON) indicated R1 was noted to have been taking Maalox frequently which was likely cause of loose stools as this is a side effect of that medication along with bloating. The note included R1 was taking the medication for full feeling/GI upset which was due to CHF and fluid overload as per ER report, and returned with medication changes. -8/31/20, another note indicated R1 had returned to the facility at 5:00 p.m., oxygen saturation was 94% with oxygen at 3L/minute per nasal cannula and had no further loose stools. Shortness of breath was noted only with cares when R1 was lying flat or being moved around. -9/1/20, order was received for [MEDICATION(S)] 40 mg a day, potassium 20 equivalents a day and to follow up with primary MD in one week. -9/1/20, another noted indicated R1 was up in her wheelchair, visiting with her spouse and had stated she felt better. R1 appeared better in color and abdomen had decreased slightly. R1's progress notes lacked any documentation of the medication errors that had occurred 8/12/20 through 8/31/20. R1's weight log from 7/23/20 through 9/1/20, revealed the following weights: -7/23/20 R1's weight was 206 lbs. -7/27/20 R1's weight was 208 lbs. -8/3/20 R1's weight was 209 lbs -8/6/20 R1's weight was 210 lbs. -8/10/20 R1's weight was 216 lbs -8/17/20 R1's weight was 212 lbs. -8/24/20 R1's weight was 212 lbs. -9/1/20 R1's weight was 209 lbs. R1's weekly weights were not documented in her record for the weeks of 8/3/20, 8/10/20 and 8/17/20. A copy of the facility's internal investigation of R1's medication errors was requested, and the facility provided a copy of the facility's 5 day investigative report for R1 and a copy of R1's August 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The note dated 9/2/20, indicated regarding the medication error for R1, a staff member reported the Las label indicated the [MEDICATION(S)] in the cassette was 20 mg and in smaller print instructions listed to administer one-half tablet and since the pill was smaller, felt it was difficult to see if the tablet was split. The facility had spoken with the pharmacy and been informed the label is required to identify the strength of the tablet, and would check with their software company to see if the font size of instructions could be made larger. R1's 5 day investigative report completed by the facility, dated 9/1/20, listed R1 had an increase in [MEDICATION(S)] from 10 mg to [MEDICATION(S)] 20 mg on 8/11/20, however, R1 continued to receive 10 mg of [MEDICATION(S)] in error until after treatment at the ER 8/31/20, when a staff member questioned why R1 had such a jump in the [MEDICATION(S)] from 10 mg to 40 mg. The report listed the same cartridge was present in the medication cart, and pharmacy had not received the new order for [MEDICATION(S)] 20 mg. The report identified R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The report identified R1 had been hospitalized in the past for CHF, not sure if the medication error contributed to R1's fluid overload diagnosed on [DATE]. Review of R1's MAR for August 2020 indicated [MEDICATION(S)] 10 mg was administered daily 8/1/20 through 8/11/20. A second order was entered on 8/11/20 to administer [MEDICATION(S)] 20 mg daily and was initialed as given daily 8/12/20 through 8/30/20. On 8/31/20, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was correctly transcribed onto the MAR, however, there is no evidence the pharmacy had been notified of dose change. Review of R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/10/20, at 10:27 a.m. R1 was observed seated in her wheelchair in the hallway, with oxygen tubing in her nares. R1 appeared pale, calm with no cough was noted and R1 was able to converse without shortness of breath noted. No [CONDITION(S)] was observed in her lower extremities. On 9/10/20, at 8:40 am. LPN-A confirmed she had administered the wrong dose of [MEDICATION(S)] to R1. LPN-A stated R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN-A verified the increase in [MEDICATION(S)] was not recorded in the shift change report book that was used to alert other staff of resident changes. LPN-A stated she felt if the medication cassettes were double checked against the orders when they came in from pharmacy, the medication administration errors could have been prevented. On 9/10/20, at 3:34 p.m. RN-A verified she had forgotten to record the medication adjustment on the shift report book. RN-A stated transcription of orders was double checked by the health unit coordinator (HUC) and the nurse, however, the ordering of the medication and removing the discontinued medication did not have a double check system. RN-A stated she felt she was sure she had ordered the increase dosage of [MEDICATION(S)] from the pharmacy, however, she had not saved the fax communication form sent to the pharmacy. RN-A verified a medication error had occurred involving 5 different licensed staff over the course of 19 days. On 9/11/20, at 10:40 a.m. DON confirmed R1 had received the incorrect dose of [MEDICATION(S)] between 8/11 and 9/1/20. She indicated she felt the label on the cassette may have been confusing and hard to read. She also stated she felt there was a miscommunication between the pharmacy and the facility. She indicated she had provided 1:1 education with the five licensed staff members directly involved in the significant medication error regarding the 6 rights of medication administration. DON stated prior to R1's medication error, the QA committee had discussed scheduling an in-service on high risk medications and medication errors, however, no dates had been scheduled at the time of the medication error. On 9/11/20, at 2:15 p.m. the DON stated she had done random, informal spot checks, comparing the individual residents' MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/11/20, at 2:38 p.m. a telephone interview was conducted with the facility's consultant pharmacist. The pharmacist verified the missed increase in the [MEDICATION(S)] was a significant medication error and confirmed a missed medication for that length of time was not ideal and would have consequences. The pharmacist stated it was a long time between the medication error and symptoms getting worse, so as far as severity, it would be difficult to tell if the medication error contributed. On 9/14/20, at 1:00 pm a telephone interview was conducted with R1's primary medical doctor (MD), the MD identified if the [MEDICATION(S)] had been administered as ordered and R1 had responded to the increase dose, it could possibly have changed the course of R1's illness and possibly avoided emergency intervention. The physician stated he did not feel the error ultimately contributed to R1's death, in light of the course of her illness and previous hospitalization s. The facility's policy, titled, Policy for Identifying Early Changes in Condition and Reducing Unnecessary hospitalization s, dated 4/25/19, identified changes in condition to include residents seeming different than usual, a weight change, being more tired, weak, confuse, or agitated than usual. or having a change in vital signs or respiratory status. The policy directed staff, if the resident could be safely monitored in the facility, to take appropriate measures to ensure proper communication amongst staff members so that the resident's condition continues to be monitored until the change in condition has resolved. The facility's policy titled, Medication Ordering, dated 11/20/17, indicated that no resident in the facility shall be with out any of the medications that have been ordered by their primary medical doctor (MD). If a medication that has been ordered has not been delivered, staff needed to notify the unit manager for follow up. The facility's policy titled, Medication Administration, dated 1/6/20, indicated the six rights of medication administration should be followed with each medication or treatment. These include: right resident, medication, dose, time, route, documentation. The policy also directed staff three checks were to be done with each medication or treatment to ensure they are correct. The IJ that began on 8/12/20, was removed on 9/16/20, at 12:00 p.m. when the facility developed and implemented the following interventions which were verified through observation, document review and interview: -audited all residents that received diuretic medications to ensure correct doses where present in their medication cassettes and verified correct dose when compared against resident MAR's and physician orders. -educated licensed nursing staff and trained medication aides (TMA's) regarding high risk medications and medication errors. -development of medication transcription sheets to be used in the shift report book which would list residents with medications changes along with a checkbox to remind and ensure that the medication has been removed from the cart, if applicable. -training licensed nursing staff and TMA's on new policy and procedure for transcribing orders. -competency testing of licensed staff and TMA's to ensure competency with medication pass best practice and will be added to staff's annual review. -consult with pharmacy on changes in medication labels. -developed an auditing system to ensure compliance with diuretic medications is sustained for all residents receiving diuretics.

Based on observation, interview and document review, the facility failed to ensure a resident identified at risk for pressure ulcers received timely repositioning in order to prevent the development of pressure ulcers for 1 of 6 residents (R16) in the sample identified at risk for pressure ulcers. Findings include: R16's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R16 had [DIAGNOSES REDACTED]. The MDS also indicated R16 had a suprapubic catheter (bladder catheter inserted through the abdominal wall), was at risk for pressure ulcers and required extensive assistance of 1-2 staff with all activities of daily living. R16's Pressure Ulcer Care Area Assessment (CAA) dated 7/12/18, indicated R16 required extensive assistance with mobility and required assistance with repositiong every 2 to 3 hours to prevent pressure ulcers. R16's Braden Assessment (tool used to determine pressure ulcer risk) dated 9/28/18, indicate R16 was at low risk for the development of pressure ulcers. R16's mobility assessment dated [DATE], indicated R16 required assistance with repositioning and assistance of one staff for ambulation. R16's Care Plan dated 5/18/18, directed the staff to assist with repositioning every 2-3 hours. On 3/13/19, from 2:53 p.m. to 6:54 p.m. R16 was continuously observed to remain seated in his wheelchair. -At 2:53 p.m. R16 was seated in the wheelchair drinking coffee in the main dining room. -At 3:00 p.m. R16 wheeled himself from the dining room to the area next to the bird aviary. -At 4:30 p.m. R16 wheeled himself back into the dining room. -At 4:52 p.m. R16 wheeled up to a table and helped himself to a carton of chocolate milk. -At 5:00 p.m. R16 wheeled around the dining room. -At 5:35 p.m. R16 was assisted to his assigned dining room. -At 5:48 p.m. R16 was served the evening meal. -At 6:40 p.m. R16 remained in the dining room. Nursing assistant (NA)-F stated the NA's kept track of the residents in need of assistance with repositiong on a slip of paper which was in the utility room. NA-F reviewed the paper and reported R16 had a catheter, therefore he had not been assisted since she had arrived at the facility at 3:00 p.m. NA-F stated she did not know when the last time R16 had been assisted with repositiong. -At 6:55 p.m. NA-F assisted R16 to the rest room. R16 was able to stand with assistance of one staff. R16's wheelchair was equipped with a pressure redistribution cushion. R16's skin was observed to be pink and intact. -At 7:00 p.m. NA-F reviewed the computer documention and reported R16 had last been assisted with repositiong at 2:15 p.m. a total of 4 hours and 45 minutes earlier. On 3/14/19, at 7:13 a.m. R16 was observed in the dining room, seated in his wheelchair. -At 7:19 a.m. R16 wheeled himself to the nurse's station. -At 7:23 a.m. R16 returned to the dining room. -At 8:22 a.m. R16 had finished breakfast and propelled himself down the 400 wing hallway. -At 8:41 a.m. R16 propelled himself to the fireplace on the transitional care unit (TCU). -At 9:11 a.m. R16 was escorted from the TCU to the lobby by the dining room. -At 9:45 a.m. registered nurse (RN)-A assisted R16 to the rest room. R16's wheelchair was observed to be equipped with a pressure redistribution cushion. R16's skin was observed to be pink and intact. -At 10:10 a.m. NA-G and NA-H stated R16 was in the wheelchair when they arrived on the floor at 6:30 a.m. The NAs confirmed R16 had not been assisted with repositiong for a total of 4 hours and 15 minutes. -At 11:27 a.m. RN-A stated R16 was to receive assistance with repositiong every two to three hours as directed by the care plan. When questioned how the repositiong interval was determined, RN-B stated the facility standard was to reposition all residents every two to three hours. RN-A confirmed R16's clinical record lacked an individualized comprehensive skin assessment which would identify the repositioning needs for R16. On 3/15/19, at 8:12 a.m. the director of nurses (DON) stated the facility completed Braden scale assessments to determine the repositioning needs of the residents. The DON confirmed the clincial record did not include a comprehensive evaluation of R16's skin needs, however, confirmed he was to be assisted every 2-3 hours as directed by the care plan. The DON confirmed R16 should not have sat greater than 4 hours without assistance in repositiong. The Facility Policy and Procedure on Skin Assessment and Preventative Skin Care dated 2/26/19, directed the staff to complete an interdisciplinary comprehensive skin assessment upon admission, quarterly and as needed to reduce the risks and implement an interdisciplinary plan of care to prevent/minimize the development of pressure ulcers.

Based on observation, interview and document review, the facility failed to ensure suprapubic (tubing surgically inserted through the anterior abdominal wall into the bladder) catheter tubing was cleaned when accessed in order to prevent contamination for 1 of 2 residents (R16) observed with a suprapubic urinary catheter. Findings include: R16's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R16 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS also indicated R16 required extensive assistance of 1-2 staff with all activities of daily living and R16 utilized a suprapubic catheter. R16's Care Plan dated 5/17/18, indicated R16 utilized a suprapubic catheter due to [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. The care plan directed the staff to empty the catheter drainage bag every 2-3 hours. On 3/13/19, at 6:54 p.m. nursing assistant (NA)-F was observed to wheel R16 into his bathroom. While seated on the toilet, NA-F to place a urinal on the floor and pull up R16's pants leg which exposed a urine drainage bag. NA-F donned gloves, placed the urinal directly onto the floor, opened the catheter bag's drainage valve and drained urine into the urinal. Once emptied, NA-F recapped the drainage port and placed the urinal to the side. NA-F was not observed to utilize a barrier between the urinal and the floor in order to protect from spills or splashes, nor was she observed to cleanse the port of the drainage tubing with alcohol before or after accessing it. On 3/14/19, at 9:52 a.m. registered nurse (RN)-A was observed to assist R16 onto the toilet. Once on the toilet, RN-A obtained a urinal, placed it on the floor and exposed the R16's catheter drainage bag. RN-A opened the the catheter's drainage port, emptied the urine into the urinal, closed the port and patted it dry with a small piece of toilet tissue. At no time was RN-A observed to utilize a barrier between the floor and the urinal or utilize an alcohol wipe the drainage port prior to and after emptying. -At 10:10 a.m. RN-A confirmed she did not place a barrier between the floor and the urinal in case of spills or splashes. RN-A stated she had utilized the toilet tissue because she did not have any alcohol wipes with her. The facility Infection Prevention and Control Manual Resident Care Prevention of Catheter-Associated Urinary Tract Infection dated (YEAR), directed the staff to utilize an alcohol wipe between opening and closing the urinary drainage system. The policy did not direct the staff to place a barrier between the floor and the urine receptacle. On 3/15/19, at 8:12 a.m. the director of nurses (DON) stated the catheter drainage port was to be cleansed with an alcohol wipe after use. The DON confirmed the policy did not direct the staff to place a barrier between the floor and the urine receptacle, however, a barrier should have been used. The Care and Management of Patients with Urinary Catheters: A Clinical Resource Guide indicated catheter care standards included performing hand hygiene before and after manipulating the catheter drainage system, use a new pair of non-sterile gloves with each patient, and when emptying the drainage bag, use a separate, clean container for each patient and avoid contact between the tap (valve) and the container, and to wipe the tap with alcohol.

Based on observation, interview and document review, the facility failed to maintain confidentiality for 3 of 3 residents (R1, R15, R45) whose Personal Health Information (PHI) was observed posted in their rooms visible to all who entered. Findings include: On 3/13/19, at 2:47 p.m. R1's bulletin board which hung in his room had a sign posted in on it which read: Assist of 1, Stand By Assist (SBA) of 1 with transfers and ambulation. The information was visible to all who entered the room. -At 2:50 p.m. R15's bulletin board which hung in his room had a sign posted on it which read: Assist of 2 with Hoyer for all transfers. Non-ambulatory. The information was visible to all who entered the room. -At 2:58 p.m. R45's bulletin board which hung in his room had a sign posted on it which read: Assist of 2 with hoyer, use PAL lift in sauna. The information was visible to all who entered the room. On 3/15/19, at 8:34 a.m. nursing assistant (NA)-E stated the signs posted in the aforementioned resident rooms which contained resident care information could be seen as an invasion of privacy, but it would not personally bother her. -At 8:47 a.m. NA-D stated the facility started posting the signs in the rooms when they had more new staff starting. NA-D also stated the facility kept a Kardex (card with patient care information) in the bottom of each resident's drawer, out of site of visitors, which contained individualized care information and used for the staff to find care information such as transfer needs. NA-D said she personally would not want the information posted on the bulletin board in the room for all to see. -At 8:57 a.m. registered nurse (RN)-C stated she was told the information posted was not protected personal health information because it did not have the resident's name on it. RN-C stated a person who entered the room could probably assume the information would be about the residnet for whose room it was posted if there was only one resident residing in the room or if the information was posted on a board next to the resident's bed, then the signs could be considered an invasion of privacy. RN-C stated there was a Kardex in the bottom drawer in each residents' room with personal information which was kept out of the view of others and could also have transfer information identified on it as well. - At 9:07 a.m. Director of Nursing (DON) stated she could see how the posted information could be considered protected health information and that the information could be stored privately, if they wanted, in a drawer in each resident's room, out of the view of all who entered the room. When asked, the DON stated yes, it could be a privacy issue with the resident. The United States Department of Health and Human Services states PHI is any individually identifiable health information which relates to the individual's past, present or future physical, mental health or condition; provisions of health care to the individual.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R47) received the application of a left arm splint as directed by the physical therapist. Findings include: R47's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R47 had dementia, displayed severe cognitive impairment, required extensive to total assistance with all activities of daily living, and displayed bilateral limited range of motion. A physician's orders [REDACTED]. A Rehab Communication to Nursing form dated 7/28/17, indicated the occupational therapist had discharged R47 from therapy and R47 was to wear a blue functional hand splint on her left arm during the day and a left elbow brace at night. R47's care plan dated 11/26/16, directed the staff to assist R47 in nursing rehab as directed. R47's electronic Treatment Administration Record (ETAR) directed the nursing staff to place a blue hand splint on the left hand after gentle range of motion to the fingers. The splint was to be applied in the morning and removed at bedtime. The January 2018, ETAR indicated R47 had received daily application of the splint. A Nursing Progress Note dated 12/13/17, at 11:48 a.m. indicated R47 utilized the left hand splint daily, however, R47 was resistive to range of motion had would yell during stretching exercises. On 1/29/18, at 11:00 a.m. R47 was observed resting in her bed. R47's left had was in a fisted position without any type of hand splint in place. A hand roll (soft terrycloth roll with velcro straps) and a left hand splint were noted on R47's bedside stand which was positioned next to R47's bed. - At 3:56 p.m. R47 was observed resting in bed. The splint and hand roll remained on the bedside stand. On 1/30/18, at 12:00 p.m. R47 was observed seated in a wheelchair in the dining room. R47 had a hand roll in her left hand. - At 3:40 p.m. R47 was resting in bed with the had roll in her left hand. - At 5:14 p.m. R47 was wheeled into the dining room for supper. R47 had a hand roll in the left hand. - At 5:45 p.m. R47 was assisted with the evening meal. R47 continued to have the hand roll in her hand. - At 7:30 p.m. R47 continued to have a left hand roll in her left hand. On 1/31/18, at 7:00 a.m. R47 was observed to be out of her room. R47's hand roll and left hand splint were observed on the bedside stand. - At 7:30 a.m. R47 was observed in the dining room eating breakfast. R47's left hand was in a fisted position without any type of splinting device in place. - At 9:30 a.m. nursing assistance (NA)-A and NA-C were observed to transfer R47 into bed via a full body mechanical lift. Once in bed, and cares provided, NA-A and NA-C did not apply R47's left hand splint. - At 9:42 a.m. NA-A confirmed R47 was to utilize the hand splints daily and stated she would place the splints when R47 was assisted up for lunch. - At 11:42 a.m. R47 was observed in the dining room. R47 had a hand roll in her left hand. - At 12:23 p.m. restorative aide (RA)-A stated R47 received range of motion services three times a week by the restorative staff, however, R47 was to wear the left hand splint daily. The splint was to be applied in the morning and removed at bedtime. R47 was allowed to have the splint removed at meals. RA-A confirmed R47 did not have a splint in place and proceeded to R47's room, found the splint and completed gentle range of motion to R47's left hand fingers. R47's hand fingers were contracted approximately 45 degrees but was able to be straighten them enough to place the left hand splint. R47 cried out when her left hand was moved, but stopped crying when RA-A stopped moving her hand. RA-A stated R47 typically cried out when the range of motion services were provided and when RA-A provided range of motion services to R47 she generally wrapped the left arm in a warm blanket to calm her prior to the exercise. RA-A stated R47 was to utilize the left hand splint during the day and she did not know why R47 had a hand roll. - At 12:57 p.m. registered nurse (RN)-A stated R47 was to utilize a left hand splint during the day, which could be removed at meals. R47 was to receive assistance to place the splint in the morning and removed at bedtime and was unaware R47 was utilizing a hand roll. Upon review of R47's clinical record, RN-A confirmed the medical record lacked documentation of when a hand roll was given to R47 or why. RN-A confirmed R47 had not received the application of the splint as directed by therapy and the care plan. - At 1:08 p.m. restorative licensed practical nurse (RLPN) confirmed R47 was to utilize a left hand splint daily and was unaware R47 had a hand roll. RLPN stated the wing nurses were to document the placement of the left hand splint. - At 1:10 p.m. LPN-A stated she documented in the ETAR daily that R47 was to wear a hand splint. LPN-A stated she did not know why the splint had not been applied as directed and did not know why R47 had a hand roll. LPN-A stated an occupational therapist who was no longer at the facility may have applied the hand roll. - At 1:15 p.m. RN-A reported she had spoken to a contract certified occupational therapy assistant (COTA) and reported the COTA thought the hand splint had been in need of repair therefore the hand roll had been placed in the interim. However, upon review of R47's medical record, RN-A confirmed R47's record lacked documentation related to the hand roll and stated the splint was to be applied as directed. At- 1:55 p.m. the director of nurses (DON) stated R47 was to utilize the left hand splint as directed by the occupational therapy recommendations. The Splinting and or Braces policy dated 4/3/16, directed the staff to apply splint and other orthotics as directed to prevent contractures or deformities. The Care Plan policy dated 11/28/16, directed the staff to provide care according to the individual comprehensive care plans.

Based on observation, interview and document review, the facilty failed to ensure hospice services were coordinated with the hospice provided for 1 of 1 resident (R47) reviewed who received hospice services. Findings include: R47's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R47 had dementia, displayed severe cognitive impairment, required extensive to total assistance with all activities of daily living, and received hospice services. R47's significant change MDS dated [DATE], indicated R47 displayed severe cognitive impairments and was diagnosed with [REDACTED]. The Activities of Daily Living Care Area Assessment (CAA) dated 10/18/17, indicated R47 had been placed on hospice service following a hospitalization due to aspiration pneumonia. R47's medical record contained a hospice note dated 9/26/17, which indicated hospice services had been initiated following a hospitalization for aspiration pneumonia. The plan indicated R47 would receive nursing and social service visits. R47 did not require hospice aide services as they would be provided by the facility. R47's care plan dated revised on 9/27/17, indicated R47 was receiving hospice services. The care plan did not indicate how often hospice would visit or the types of services hospice would provide. On 1/30/18, at 4:27 p.m. R47 was observed resting in bed. The hopsice licensed social worker (LSW) was seated next to R47's bed visiting with R47. The hospice LSW stated she visited R47 once a week. The LSW stated she did not notify the facility when she would visit, but confirmed she did visit weekly. - At 5:07 p.m. the hospice LSW was observed to leave R47's room. Review of R47's hospice notes from 9/26/17 - 1/9/18, indicated R47 had received weekly visits from the hospice nurse and/or LSW. - On 1/31/18, at 8:45 a.m. nursing assistant (NA)-B stated she was aware R47 was receiving services from hospice, however, NA-B was unaware when the hospice staff would be visiting or what services they would provide to R47. - At 9:12 a.m. NA-C stated she was aware hospice staff members visited with R47, however, NA-C did not known when the hospice staff would be at the facility or the services they provided. - At 9:14 a.m. NA-A stated R47 received assistance with pain management from the hospice staff, but was unaware when the hospice staff visited with R47. - At 12:50 p.m. registered nurse (RN)-A stated the hospice nurse and social worker visit R47 weekly, however, the hospice agency did not provide the facility with a schedule or notice prior to their arrival. RN-A stated when hospice staff did come to the facility, they would ask the medication nurse or stop into her office to check on R47's status prior to visiting with R47. RN-A confirmed she did not know when the hopsice staff would be at the facility as they did not notify the facility prior to their arrival. RN-A stated the hospice nurse and LSW had visited with R47 on 1/30/17. - At 1:55 p.m. the director of nurses (DON) stated the facility was provided with hospice services by two different hospice agencies. The DON explained one hospice agency notified the facility prior to their arrival, however, the other provider (the one serving R47) did not notify the facility when they would be visiting the facility. The DON confirmed the direct care staff should be aware of when the hospice staff would be in the facility to ensure ongoing coordinated medical care. - At approximately 2:00 p.m. a phone call was placed to the hospice nurse without success. On 2/1/18, at 10:30 a.m. the administrator stated she had been made aware of the concern related to hospice coordination of care. The administrator stated the hopsice provider would be contacted to enhance communication between the provider and the facility. The Hospice policy dated 11/2017, indicated when a resident participated in a hopsice program, a coordinated plan of care between the facility, the hospice agency and the family would be developed.

Based on interview, and document review, the facility failed to provide activities to meet the individual interests for 3 of 3 cognitively impaired residents (R47, R45, R48) in the sample who were reviewed for activities. Findings include: R47's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R47 had dementia, severe cognitive impairment, and required extensive to total assistance with all activities of daily living R47's Activity Interest assessment dated [DATE], indicated R47 worked in a grocery store, attended church services, had past hobbies such as gardening, reading, and spending time with her family and pets. R47's current interest included listening to much, attending church services and pet visits. R47's Activity Assessment review dated 10/12/17, indicated R47 was to be assisted to activities as tolerated. R47 was to be provided a stuffed cat to hold and the staff were to provide one to one (1-1) activities as tolerated. R47 enjoyed activities such as talking about her cats and was to be informed of music and church activities and assisted to attend those activities, as needed. R47's care plan updated on 1/31/18, indicated R47 was to be assisted to activities of her choosing. Staff were to inform her of activities, R47 enjoyed Bingo, visits from a dog, church services, music, special events, food fun and patio time. The activity staff were to conduct 1-1 visits as needed and provide her a stuffed cat for comfort. The Activity Calendar dated 1/29/18, identified the following activities: 9:30 a.m. manicures 2:00 p.m. Sing a long 3:00 p.m. Cathodic Mass 3:15 pm. 1-1 visits On 1/29/18, at 9:30 am. the activity staff were observed in the activity room providing manicures. R47 was not observed in the activity area. - At 3:00 p.m. R47 was observed resting in bed. R47 was not observed to attend the sing a long, catholic mass or 1-1 visits. Review of R47's Point of Care (P(NAME)) Legend Report (daily activity documentation) dated 1/29/18, indicated R47 had received a 1-1 visit. The Activity Calendar dated 1/30/18, identified the following activities: 10:00 a.m. Bingo / Easy Listening 2:00 p.m. Spruce Grove Church 3:15 p.m. 1-1 visits At 3:40 p.m. R47 was observed resting in bed. R47 was continuously oberseved from 4:00 p.m. to 8:00 p.m. during which time R47 was not observed to be offered or participate in any type of social or spiritual activity. The Activity Calendar dated 1/31/18, identified the following activities: 10:00 a.m. Bingo / Easy Listening 1:30 p.m. Food Fun 3:30 p.m. Social hour - At 9:30 a.m. activity aide (AA)-A stated she visited with every resident in the facility twice a day to see if they wanted to join the morning or afternoon activities. AA-A stated she had a busy morning ahead as it was Bingo day. AA-A was then observed to walk down the hallway stopping by each room and exiting the room. AA-A was not observed to be in each room for more than 30 seconds. - At 10:00 a.m. Bingo was observed in session, however, R47 was not participating as R47 was in bed. - At 1:30 p.m. the activity staff were observed to serve fresh doughnuts and coffee to the residents in the activity room. R47 was not in the activity room and was not served a doughnut. - At 3:00 p.m. R47 was observed in bed. Review of R47's P(NAME) documentation for 1/31/18, was not available. On 1/31/18, at 1:30 p.m. AA-B stated R47 was very social and enjoyed attending activities. AA-A stated R48's participation varied as she often was observed to rest during the day. AA-B stated the facilty did not provide activities after 4:00 p.m. R45's quarterly MDS dated [DATE], indicated R45 had [DIAGNOSES REDACTED]. The MDS also indicated R45 had moderate cognitive impairment, displayed feelings of being tired and having little energy, and required extensive assistance for all activities of daily living. R45's Activity assessment dated [DATE], indicated R45 preferred to stay in his room. R45 enjoyed country music activities, television, listening to sporting events. The activity staff were to provide 1-1 visits as needed to visit about farming, logging and fishing in Alaska. R45 required assistance to all purposeful destinations. R45's Care Plan dated 12/2/15, indicated R45 preferred to stay in his room or to sit in the front lobby for short periods of time prior to meals. R45 declined group activities and he was to be provided 1-1 visits as he allowed which was to include socializing, pet visits and conversations about fishing, farming and logging. The Activity Calendar dated 1/29/18 identified the following activities: 9:30 a.m. manicures 2:00 p.m. Sing a long 3:00 p.m. Cathodic Mass 3:15 pm. 1-1 visits On 1/29/18, at 9:30 am. the activity staff were observed in the activity room providing manicures. R47 was not observed in the activity area. - At 10:50 a.m. R45 was observed resting in bed with the lights off and curtains closed. - At 1:30 p.m. R45 was observed resting in bed with the lights off and curtains closed. The television and radio were off. Review of R45's P(NAME) documentation dated 1/29/18, indicated R45 had received a 1-1 visit. The Activity Calendar dated 1/30/18, identified the following activities: 10:00 a.m. Bingo / Easy Listening 2:00 p.m. Spruce Grove Church 3:15 p.m. 1-1 visits - At 3:30 p.m. R45 was observed resting in bed with the lights off and curtains closed. - At 4:00 p.m. licensed practical nurse (LPN)-B stated the activity staff members left the facility by 4:00 each day and confirmed there would be no activities in the facility after 4:00 p.m. On 1/30/18, from 4:00 p.m. to 8:00 p.m. other than eating the evening meal in the dining room, no type of social activity was offered or provided R45 during this time frame. The Activity Calendar dated 1/31/18, identified the following activities: 10:00 Bingo / Easy Listening 1:30 p.m. Food Fun 3:30 p.m. Social Hour. - At 10:00 a.m. R45 was observed sleeping in bed. - At 12:12 p.m. registered nurse (RN)-B stated R45 would occasionally attend activities, but R45 did not stay in activities long. R45 enjoyed sitting outside in the summer, however, during the winter months, R45 spent the majority of his time in bed. - At 1:30 p.m. food fun was observed in the activity room. R45 was not observed to attend the activity. R45's P(NAME) documentation for 1/31/18, was not available for review. R48's admission MDS dated [DATE], indicated R48 had severe cognitive impairment and [DIAGNOSES REDACTED]. The assessment indicated R48 required extensive assitance of one staff for activities of daily living. R48's Activities Participation Review assessment dated [DATE], indicated R48 declined to participate in group activities. R48 spent the majority of his time in his room or watching the hallway activity from his doorway. R48 was to be provided 1-1 visits greater than two times a week. R48 had little to no hobbies in the past and conversations usually pertained to finding his wife and how confused he felt. It was difficult to discuss other topics with R48. R48's Care Plan dated 1/2/08, indicated R48 required diversal activities but stated he had no hobbies or interests. The plan directed the staff to ensure R48 was independent with his activity choices and directed the staff to provide 1-1 activities two times a week. The Activity Calendar dated 1/29/18, identified the following activities: 9:30 a.m. manicures 2:00 p.m. Sing a long 3:00 p.m. Cathodic Mass 3:15 pm. 1-1 visits - At 9:30 a.m. R48 was not observed to participate in the manicure activity. - At 2:00 p.m. R48 was observed sitting in his room. - At 3:00 p.m. several residents were observed drinking coffee and eating snacks in the main dining room. R48 was observed seated on the edge of his bed weeping. R48 stated he was missing his wife. Review of R48's P(NAME) documentation dated 1/29/18, indicated R48 had received a 1-1 visit., socialization, played a game and had company. The Activity Calendar dated 1/30/18, identified the following activities: 10:00 a.m. Bingo / Easy Listening 2:00 p.m. Spruce Grove Church 3:15 p.m. 1-1 visits - At 10:00 a.m. R48 was not observed in the Bingo activity. - At 3:40 p.m. R48 was observed in his room. R48 stated he did not attend the church service or Bingo. - At 6:00 p.m. R48 was observed to visit with his wife. Review of the 1/30/18, P(NAME) documentation indicated R48 had received a 1-1 visit. The Activity Calendar dated 1/31/18, identified the following activities: 10:00 Bingo / Easy Listening 1:30 p.m. Food Fun 3:30 p.m. Social Hour. - At 10:00 a.m. R48 was observed resting in bed. - At 1:30 p.m. food fun was observed in the activity room. R48 was not observed to attend the activity. The P(NAME) documentation for 1/31/18, was not available for review. On 1/31/18, at 1:30 p.m. AA-B stated the residents were to receive a 10-20 minute 1-1 activity daily. AA-B stated R48 frequently seemed very sad when she visited with him, but he was to receive daily visits. AA-A stated when the 1-1 visits were conducted, the staff documented the activity occurred in the P(NAME) system. However, the activity staff did not document how long the activity was or what type of 1-1 activity was provided. Review of R47, R45 and R48's P(NAME) documentation indicated all three residents received a daily 1-1 visit from the activity staff, however, the records lacked documentation related to the length of visit or activity provided during the visit. On 2/1/18, at 9:50 a.m. the activity director (AD) confirmed most of the 64 residents in the facility received a one to one visit by the activity staff on a daily basis and the visits were to be between 10-30 minutes long. The AD stated the facility had two activities aide who also held at least three large group activities per day which lasted between 30 minutes to a hour each. The AD confirmed the staff did not have the ability to document the topics or length of 1:1 visits in the computer system therefore the facility did not have a record of the 1-1 visits. The AD confirmed the activity documentation was skewed and the residents' may not have been receiving the visits as directed. Upon review of R47, R45 and R48's care plans, the AD confirmed the care plans did not include goals which would identify the number of activities each resident was to attend and did not identify individual activity goals for the residents. The AD confirmed the facilty did not have activities after 4:00 p.m. as most of the residents wanted to go to bed. The AD stated in the past, a resident had initiated activities in the evening, however, that resident had passed away. The AD stated she was working with a new volunteer to provide activities in the evening because the activity staff did not provide them. The AD confirmed R47, R45 and R48's care plans were in need of revision to include individualized activities and the frequency of. The AD stated the facilty did not have any type of policies related to individualized activities.

Based on observation, interview and document review, the facility failed to maintain sanitary storage of personal resident oxygen equipment/tubing for 6 of 6 residents (R2, R90, R52, R42, R6, R25) observed to have nasal oxygen tubing lying on the floor or touching unclean surfaces without a barrier for protection from contamination. In addition, the facility failed to maintain a sanitary and cleanable surface for 1 of 1 resident (R20) observed to have a grab bar wrapped in foam and taped on with duct tape which rendered it uncleanable. Findings include: On 11/30/16, at 11:56 a.m. R2's nasal cannula (tubing device used to deliver oxygen through the nose) and oxygen tubing was observed unprotected and lying on the floor in the resident's room. On 11/30/16, at 11:50 a.m. R90's nasal cannula tubing was observed draped over the oxygen concentrator with the nasal cannula up against/touching the concentrator's electrical cord. On 11/30/16, at 11:46 a.m. R52's oxygen tubing was observed draped over R52's grab bar on the bed with the nasal cannula lying directly on the floor touching the waste basket. On 12/1/16, at 8:36 a.m. R52's oxygen tubing and nasal cannula was observed lying directly on the floor. On 11/30/16, at 7:43 a.m. R42's oxygen tubing was observed draped over the oxygen concentrator with the nasal cannula hanging close to the floor. On 12/1/16, at 8:42 a.m. R42's nasal cannula tubing was observed draped over the unmade bed touching the bare mattress. On 12/1/16, 8:34 a.m. R6's nasal cannula tubing was observed draped over the oxygen concentrator with the nasal cannula touching the back side of the concentrator with no barrier for protection. On 11/30/16, at 7:50 a.m. R25's nasal cannula tubing was observed draped over the oxygen concentrator with the nasal cannula resting up against a heating vent behind the concentrator and on 12/01/16, at 8:34 a.m. R25's nasal cannula and tubing was observed lying on the floor with no protection or covering. On 12/1/16, 10:20 a.m. the director of nursing (DON) completed a tour of the above residents' rooms and verified the nasal cannula's were laying on the floor and touching unclean surfaces with no covering or protection. The DON stated the tubing should be wound up so the nasal cannula could at least hang on the knobs of the concentrator. The DON stated the tubing and nasal cannula's were not being stored in a sanitary manner but was not certain what the facility policy was. Grab Bars On 11/29/16, at 11:05 a.m. R20's bed was observed equipped with bilateral grab bars which were covered with grey foam and dark duct tape which created an uncleanable surface. On 12/1/16, at 10:45 a.m. registered nurse (RN)-F stated she was not aware any one had grab bars covered in foam. RN-F stated no one in the facility was to have foam and duct tape on their grab bars because there was no way to clean or sanitize the foam. RN-F verified R20's grab bars were covered with foam and duct tape but did not know how long they had been that way. The facility Oxygen Policy, dated 6/12, indicated oxygen would be available for residents and be administered by oxygen concentrator or tank while in building. An undated cleaning policy was provided and indicated Oxygen Cannula's were to be changed every two weeks and as needed. The policies did not indicate how the cannula's and tubing were to be stored. A grab bar policy related to cleaning and sanitization was not obtained.

Based on observation, interview and document review, the facility failed to ensure oral care was provided as directed by the care plan for 1 of 1 resident (R50) observed for morning cares who was dependent on staff for assistance with oral care. Findings include: R50's [DIAGNOSES REDACTED]. R50's care plan dated 11/20/16, indicated R50 required total assistance with dressing and grooming and physical assist of one staff with oral cares using a toothbrush twice a day. The current nursing assistant assignment report directed staff to physically assist R50 with oral cares using a toothbrush twice a day. On 11/30/16, at 7:25 a.m. R50 was observed in bed with night clothes on, awake, laying on his back touching and holding on to the privacy curtain. On 11/30/16, at 8:16 a.m. nursing assistants (NA)-E and NA-F were observed to enter R50's room and provide morning cares. The NA's were observed to wash and dress R50. At approximately 8:40 a.m. R50 was transferred to the wheel chair with a mechanical lift. NA-E removed R50's lower dental partial from a denture cup on the sink and attempted to put them in R50's mouth. R50 was not accepting and became slightly agitated. NA-F stated R50 had sometimes refused to wear the dentures. After the second failed attempt, NA-E put the dental partials back in the denture cup. NA-E stated R50 had no upper teeth and no upper denture but had some teeth on the bottom and that was why it was a partial plate. NA-E proceeded to shave R50 and wheeled the resident out of the room and to the dining room. On 11/30/16, at 8:50 a.m. NA-F confirmed she had not provided R50 oral hygiene and stated R50's teeth should have been brushed or the mouth should have at least been swabbed with the toothette's before R50 was taken to the dining room. On 11/30/16 at 8:52 a.m. NA-E confirmed R50's teeth were not brushed or the mouth was not cleaned before or after she attempted to put the partial dentures in place. On 12/1/16, at 10:11 a.m. registered nurse (RN)-F verified R50's care plan directed staff to brush teeth two times a day. RN-F added, if a resident had a history of [REDACTED]. RN-F stated oral cares were important and should be done. The facility Oral Hygiene Policy revised 1/19/01, noted it was the policy of the facility to provide good oral hygiene for all residents in order to prevent infection, irritation and tooth decay. Good oral hygiene is also done to moisten the mucous membranes and to help prevent odor. An undated Resident Care Plans policy indicated the care plan shall be a personalized plan of daily care based on the nature of illness, treatment prescribed and long and short term goals. It shall include the physician's orders [REDACTED]. It shall describe the types of care needed and how they can be best accomplished, and how the plans meet the residents' needs.

Based on interview and document review, the facility failed to develop a behavioral management care plan for 1 of 1 resident (R85) who had displayed behaviors which were not identified on the care plan. Findings include: R85's [DIAGNOSES REDACTED]. admission diagnosis. R85's quarterly MDS dated [DATE], indicated R85 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 4 to 6 days in the assessment period, but less than daily. This is an increase from R85's admission MDS in which this behavior was not exhibited. R85's MDS also indicated R85 had severely impaired cognition. Review of R85's care plan lacks identification of, and subsequent goals and interventions for, refusal of care and aggressive or physically abusive behaviors towards caregivers. Review of R85's behavior progress notes since admission revealed the following refusals and behaviors directed to care: -10/17/16: R85 frequently refused oral and peri cares, resistive with cares, verbally and physically. R85 would strike out, hitting staff and hollering at them. Staff needs to leave and return again and try. -11/6/16: R85 was wandering, yelling and hitting staff, and refused cares. Res stated, everyone is always watching everything I do. -11/9/16: R85 was incontinent of urine staff attempted to take her to the bathroom, and change her brief, R85 was hitting staff. Review of the nursing assistant book at the nursing station revealed a blank page labeled behavior documentation notes. Review of R85's Point of Care documentation revealed the following behaviors were recorded by nursing assistants (documentation indicated if the behavior occurred on a shift, not the number of occurrences on a shift): August 2016 -refused peri cares one shift September: -Refused toileting one shift -Physically abusive one shift October: -Refused oral cares one shift -Refused toileting on four shifts -Refused dressing on two shifts -Verbally abusive on two shifts -Physically abusive on two shifts -Screaming, yelling, excessive noise on one shift November: -Refused toileting on six shifts -Physically abusive on six shifts -Refused oral cares on two shifts -Screaming, yelling, excessive noise on two shifts -Verbally abusive on one shift -refused an unspecified care on one shift. On 11/30/16, at 8:00 a.m. trained medication administrator (TMA)-A stated she knew how to manage R85's behaviors because of experience working with R85. On 11/30/16, at 8:10 a.m. nursing assistant (NA)-D stated R85 struck out at staff and refused cares. NA-D also stated she knew how to manage R85's behaviors because of experience working with R85. On 11/30/16, at 11:26 a.m. licensed practical nurse (LPN)-A stated the nursing assistants tracked behavior and if there was anything bad the NA's would let her know. LPN-A stated interventions would be in R85's care plan, however, she did not know what they were and would have to look them up. LPN-A suggested the surveyor ask the NA's about R85's behaviors, as she did not have additional information. On 11/30/16, at 3:14 p.m. registered nurse (RN)-B stated she did not know R85 was having these behaviors rather, knew R85 wandered and had witnessed resistance to eating, but did not know about the other behaviors. RN-B had not heard about these behaviors in report either, which was an ongoing way of gathering information on residents. RN-B stated if behaviors were noted there would be an order for [REDACTED]. On 12/1/16, at 8:32 a.m. RN-B stated she had reviewed R85's recorded behaviors with staff and they had identified them as more aggression and not physical abuse, but that was not an option. RN-B stated if the MDS nurse or the social worker thought behaviors were a problem they would notify her. On 12/1/16, at 8:40 a.m. RN-D stated behaviors documented by the NA's were reviewed by the facility social worker and the social worker entered them on the MDS. This occurs prior to the resident's care conference. On 12/1/16, at 8:43 a.m. the director of nursing (DON) confirmed R85 did not have an assessment of her behaviors nor was a behavioral care plan developed related to the behaviors. On 12/1/16, at 9;12 a.m. via telephone, the social worker (SW) confirmed R85's behaviors should have been identified. The facility Behavioral Assessment, Intervention and Monitoring policy (Med-Pass 2001, revised 2015), indicated interventions would be individualized and part of an overall care environment that supported physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. The care plan would include, at a minimum, a description of the behavioral symptoms including frequency, intensity, duration, outcomes, location, environment and precipitating factors or situations, targets and individualized interventions for the behavior and/or psychosocial symptoms and specific and measurable goals for the targeted behaviors and how the staff will monitor for effectiveness of the interventions.

Based on observation, interview and document review, the facility failed to ensure a self- administration of medication assessment was completed for 1 of 1 resident (R42) observed to self administer a nebulizer treatment. Findings include: R42's Admission Record, dated 2/3/16, indicated R42 was diagnosed with [REDACTED]. R42's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R42 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing and toileting; limited assistance with walking in her room and in the corridor, and was independent with eating and personal hygiene. R42's order summary report, printed on 12/1/16, indicated an order for [REDACTED]. On 11/30/16, at 8:45 a.m. R42 was observed alone in her room seated in her wheelchair. R42 stated she was going to do her nebulizer treatment at this time and proceeded to do so. R42 stated she does this treatment on her own. Review of R42's medical record lacked a self administration assessment (SAM), care plan or order for SAM of nebulizer treatment. On 11/30/16, at 12:15 p.m. licensed practical nurse (LPN)-B stated R42 did her nebulizer treatment on her own. LPN-B stated staff set up the medication on their morning rounds and documented that as administered on R42's Medication Administration Record [REDACTED]. LPN-B stated she would consider this self administration of medications and she did not know if there was an assessment, order or care plan in place for R42 to do self administration of her nebulizer treatment. After searching through R42's electronic record, LPN-B confirmed she could not find a SAM assessment for R42. On 11/30/16, at 12:39 p.m. the director of nursing (DON) stated if a resident was to self-administer their nebulizer treatment, their ability should be assessed by a registered nurse and care planned. The DON confirmed R42 had not been assessed for SAM ability and self administration of medication was not identified on R42's care plan and should have been. The undated facility policy titled Self-Administration of Medications indicated residents had the right to self-administer medications if determined safe to do so by the interdisciplinary team. This was also to be re-assessed quarterly, and residents were to sign a statement confirming their wish to self administer medications.

Based on interview and document review, the facility failed to provide 1 of 1 resident (R84) with appropriate room change notification. Findings include: On 11/28/16, at 6:13 p.m. R84 stated she had shared a room with her spouse up until 11/22/16, when he had passed away. R84 stated the facility's social worker (SW) had initially told R84 that she could have some time to adjust to the loss of her spouse prior to having to move into a different room. However, on 11/25/16, R84 stated the SW told her that she had to move right away, but the room she was moving into would be kept a private room for a while. R84 stated that did not happen, as she received a roommate on the same day R84 moved into the new room. R84 stated she felt like she hadn't been provided a proper notice to move nor had she been given time to adjust to the loss of her husband prior to moving. R84's progress notes/social service notes from 11/22/16, thru 11/25/16, lacked documentation that proper notice had been provided to R84 with regards to R84's room change on 11/25/16. In addition, R84's medical record lacked a Residents' Rights Regarding Room Transfer form. On 11/30/16, at 2:04 p.m. the SW stated when a resident disagreed with a room change, the Resident's Rights Regarding Room Transfer form was reviewed and completed with the resident. This form indicated if the resident disagreed with the proposed room change, the resident was provided a seven day notice that the move would occur. The resident had the right to waive this seven day notice and then could be moved at any time. The SW confirmed R84 had lost her spouse on 11/22/16, and had been moved into a different semi-private room on 11/25/16, and had received a new roommate on 11/25/16, the same day she had moved into her new room. The SW confirmed R84's move had been made due to the facility's need to accommodate a new admission. The SW stated following the death of her husband, R84 had asked him if she could have some time to adjust before she would have to be moved into a different room. The SW stated R84 was a little upset when he had given her a verbal notice on 11/25/16, that she had to be moved. The SW verified R84 had not been provided the Resident Rights Regarding Room Transfer notice prior to R84's room change. The SW confirmed if the facility had not been expecting the new admission, the facility would have allowed R84 to stay where she was a little longer which would have given her more time to grieve the loss of her spouse and adjusted to the pending room change. The SW verified R84's medical record lacked documentation regarding any discussions around R84's room change, when it had occurred, R84's reaction to the proposed room change or how R84 had acclimated to R84's new room and roommate. The SW confirmed either himself or the director of nursing (DON) were responsible for documenting R84's room change in the medical record and verified R84's medical record lacked documentation regarding any discussions around R84's room change, when it had occurred, R84's reaction to the move, or how R84 had acclimated to her new room and roommate. On 11/30/16, at 3:07 p.m. the DON stated the SW was responsible for making sure the appropriate room change notice was provided to residents when a room change was requested or needed. The DON confirmed it was expected that anytime a resident was moved this would be documented in the resident's medical record. The DON verified R84 had been moved to a new room on 11/25/16, and R84's medical record lacked documentation regarding if R84 had been provided appropriate notice of her room change. On 12/1/16, at 8:46 a.m. the administrator confirmed R84's medical record lacked documentation that proper notice had been provided to R84 prior to R84's room change on 11/25/16. Transfer, Room to Room policy dated 10/12, indicated the resident and/or guardian must be consulted about the room transfer. The resident request would be given consideration in making the transfer. In addition, the following documentation would be recorded in the residents' medical record: 1. Date and time the room transfer occurred 2. The title of the individual who assisted with the transfer 3. All assessment data obtained during the move 4. How the resident tolerated the move 5. If the resident refused the move, the reason(s) why and the interventions taken 6. The signature and title of the person recording the data. Residents' Rights Regarding Room Transfers form dated 5/6/09, indicated residents must be notified in writing, of a proposed room transfer and the justification of the room transfer no later than seven days before the transfer to another room within the facility.

Based on observation, interview, and document review, the facility failed to ensure appropriate interventions were implemented to minimize the risk of further falls/accidents based on a comprehensive assessment for 1 of 3 residents (R79) reviewed and identified at risk for falls. Findings include: R79 was diagnosed with [REDACTED]. The Fall assessment dated [DATE], indicated R79 had a history of [REDACTED]. The plan of care dated 12/21/11, directed staff to provide interventions such as a regular low wheelchair with a wedge cushion, mat on floor bedside, tab alert on bed and chair, a bed sensor alarm, bed low to floor, and a tray table attached to R79's wheelchair. On 12/29/11, at 4:49 p.m. R79 was observed to sleep in his bed. R79's wheelchair was noted at his bedside with a cushion in place. R79 was noted to have stocking feet in place. R79 was observed to have a low bed with a regular mattress, all alarms in place and a mat on the floor. At 6:21 p.m. R79 was observed to have a tray attached to his wheelchair. On 12/30/11, at 7:14 a.m. R79 was observed to be assisted with morning cares and assisting into his wheelchair. A review of the nursing progress notes and Fall Investigation Worksheets indicated: Nursing progress notes dated 11/30/11, at 8:00 p.m. indicated R79 was found on the mat on the floor next to bed. The bed alarm was sounding and the resident had stated he had work to do and had crawled onto the mat on the floor. No injuries were sustained. No investigation or assessment of the fall was completed and no further interventions were implemented. The Fall Investigation Worksheet dated 2/12/11, indicated on 2/12/11, at 3:10 p.m. R79 was noted to be scooting self forward in the solarium and slid out of his wheelchair, causing the chair to roll a distance backwards. R79 had stated he was trying to help "an old lady" who was not observed by staff. The investigation indicated R79's foot rests were in the way and the wheelchair was unlocked. Staff determined R79 needed assistance with toileting. No injuries were sustained. Interventions implemented were to ensure R79 was taken to an activity at 3:00 p.m. The investigation lacked mention at to whether the foot rests were on the resident's way or if the wheelchair rolling backwards had contributed to R79's fall. The Fall Investigation Worksheet dated 12/18/11, indicated on 12/18/11, at 10:35 p.m. R79 was found on the floor in his room after staff heard his alarm sounding. Staff stated R79 had slid out of his bed. R79 stated he was reaching for some boxes by the door; however, no boxes were present in the room. No injuries were sustained. The fall investigation revealed poor lighting and improper footwear contributed to R79's fall. R79 was asked if he needed assistance with toileting at the time of the incident and he had replied "no." Interventions included toileting the resident if he was restless, to keep him awake longer, and offer foods and fluids. The assessment did not address possible contributing factors such the poor lighting, improper footwear, or current mattress used. On 12/29/11, at 6:25 p.m. licensed practical nurse (LPN)-B stated R79 had improved with his falls but was still falling. LPN-B stated she thought R79 had rolled out of bed, but has had no mattress changes to try prevent him from rolling out of bed. The LPN stated R79 should have gripper socks on while in bed. On 12/30/11, at 7:34 a.m. LPN-A stated R79 had rolled out of bed and has had no changes in his mattress to try to prevent him from rolling out of bed. At 8:05 a.m. the director of nursing (DON) stated no fall investigation was completed for the fall on 11/30/11. She stated they thought that since the resident had reported he crawled out of bed, it was not a fall. She added R79 was not always a reliable historian. The DON stated not all factors identified as contributing to falls had been addressed. The DON stated it appeared that staff were not completing the whole process of the falls assessment and were not pulling all the contributing factors of the falls together. She stated the staff needs some education on completing root cause analysis. The DON added she is not sure all the nursing staff knows how to do this process.

Based on observation, interview and document review, the facility failed to ensure adequate supervision and interventions to minimize or prevent falls/accidents had been implemented for 2 of 3 residents (R65, R79) in the sample identified with falls. This practice resulted in actual harm when R65 experienced a fall on 11/11/10, and subsequent left hip fracture. Findings include: R65 had a history of [REDACTED]. Although R65 utilized multiple fall interventions, some of these interventions had been ineffective and possible alternative interventions and adequate supervision had not been implemented. In addition, a comprehensive assessment, of the causal factors related to the falls and the pattern of failure and ineffectiveness related to the interventions utilized to prevent falls, was lacking. R65 sustained harm on 11/11/10, related to a second fracture (left hip). R65 was admitted [DATE] with [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for falls dated 11/19/2010, indicated R65 had a history of [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], identified R65 had severely impaired memory and decision making skills. The MDS indicated R65 required extensive assistance with transfers, and toilet use, was dependent on staff for locomotion, and did not walk. The MDS identified R65's impaired balance and a history of falls without injury. The Care Area Assessment (CAA) for falls dated 11/19/2010, indicated R65 had triggering conditions of balance problems and was on an anti-depressant medication. The CAA indicated R65's fall prevention measures in place were a tab alert on the bed and chair, and a bed sensor alarm on the bed. Review of the Fall Risk Assessment Report dated 10/23/11, indicated R65 was at "high risk" for falls. The current care plan dated 5/2/11, identified R65's fall risk and directed staff to use mat on floor beside bed, tab alert on bed and chair, bed sensor alarm, bed low to floor, Lap buddy (cushion that fits across the front of a wheelchair) as ordered, extensive assist of two with bed mobility, mechanical stand lift to transfer, assess continued need for lap buddy every three months, and incontinence brief to be checked every 2 hours and changed as needed. A lip mattress was not identified on the care plan. According to the treatment record sheets, hip pads had been started prn (as needed) on 8/9/10. On 10/26/11, at 7:06 a.m. R65 was observed in a bed with a lip mattress low to the floor calling out loud enough to be heard in hallway with door closed. A sensor alarm was on the bed and an alarm was clipped to the resident. Additionally a mat was on the floor on one side of the bed and a mattress on other side of the bed. On 10/26/11, at 7:14 a.m. NA-D was observed to apply bilateral hip protector garment on R65. On 10/26/11, at 7:24 a.m. R65 was observed up in wheelchair with Lap buddy on, tab alert clipped to resident and secured to back of wheel chair. R65's wheelchair did have bars extending out bilaterally to approximately the far side of the rear wheel and approximately 3 inches from the floor. On 10/26/11, at 9:51 a.m. R65 was observed up in the wheelchair with a Lap buddy on, tab alert clipped to resident and secured to back of wheelchair. The nursing notes identified: -On 12/16/10 at 10:45 a.m. R65 was attempting to self-transfer and was found on mat on floor by bed. No injury was documented and no investigative form was provided for this fall. The Fall Tracking Log indicated R65 had sustained at least 5 more falls following the right femoral fracture on 8/5/10: -On 8/16/10, at 9:50 a.m. R65 was noted to "slipped out of homecrest chair in dayroom." -On 8/22/10, at 4:40 p.m. R65 was found laying on the floor on his stomach front of his wheelchair with a Lap buddy under his head. -On 8/24/10, at 4:30 p.m. R65 was found in room after he "appeared to have crawled out of bed." -On 9/9/10, at 6:30 p.m. R65 was found laying on his back in the front lobby. R65 reported he had bumped his head. -On 9/25/10, at 11:30 a.m. staff heard a loud noise and found R65 on his back on the floor in the dining room. -On 9/27/10, at 6:10 p.m. R65 was observed trying to get out of his wheelchair in the dining room and another resident had reported R65 bumped his head on the wheelchair. An assessment of causal/risk factors of R65's falls to ensure appropriate interventions and supervision had been implemented to try to prevent or minimize further falls/accidents was lacking. The facility did not provide any fall incident reports from 8/25/10-11/17/10. The nursing notes of 11/11/10, and Care Area Assessment (CAA) for falls dated 11/19/2010, indicated R65 had fallen from bed onto the mat on the floor and sustained harm related to a fracture of the left hip on 11/11/10. According to the treatment record sheets, hip pads were changed to on at all times 11/15/10, following R65's fall and second hip fracture. The Fall Assessment and Fall Investigation Worksheet forms identified R65 had sustained 20 falls without injuries between 11/17/11-10/9/11, but lacked reassessment and identification of any interventions to be implemented to try prevent further falls on: -On 11/17/11, at 5:45 p.m. R65 was witnessed to slide out of his wheelchair to the floor in the dining room. -On 1/17/11, at 11:10 a.m. R65 was attempting to get up from wheelchair to self transfer and appeared to have slid to floor while in the front lobby. -On 2/16/11, at 3:55 p.m. R65 was found on the floor mat at bedside. The form indicated the sensor did not alert the staff. The alarm was checked and was working, "not sure why it did not sound." -On 4/9/11, at 10:30 a.m. R65 was found on floor, had been in wheelchair, and chair alarm did not sound during the event. -On 4/20/11, at 7:50 p.m. R65 had been found on floor out of low bed with bed alarm sounding. -On 5/7/11, at 3:15 p.m. R65 was found on mat on floor out of low bed and the bed alarm had not sounded. The form indicated a new sensor alarm had been placed. -On 5/11/11, at 8:40 p.m. R65 was found on the floor out of the low bed on the mat with the bed alarm sounding. -On 5/17/11, at 2:30 p.m. R65 was found on floor on mat out of low bed with the bed alarm sounding. -On 5/21/11, at 3:20 p.m. R65 was found on floor and noted to have rolled out of bed with bed alarm sounding. -On 5/23/11, at 1:00 p.m. R65 was found on floor on mat out of low bed with the bed alarm sounding. -On 6/15/11, at 8:15 p.m. R65 was found on floor out of low bed on mat with bed and chair alarm sounding. -On 6/19/11, at 1:00 p.m. R65 was found lying on mat on the side of his bed with his head on the floor and the bed alarm sounding. -On 7/6/11, at 8:55 p.m. R65 found on the thick blue mat by the bed and the bed alarm did not sound during the event. -On 8/21/11, at 6:00 p.m. R65 was witnessed to fall forward from wheelchair to floor with chair alarm sounding. -On 9/10/11, at 1:30 p.m. R65 was found on the floor out of bed on mat with the bed alarm sounding. -On 9/11/11, at 7:00 p.m. R65 was found on the floor on the mat beside the low bed with the bed alarm sounding. -On 9/13/11, at 8:25 p.m. R65 was found lying face down on the mat next to the bed with the bed alarm sounding. -On 9/19/11, at 2:30 p.m. R65 was found on mat at bedside getting out of bed with bed alarm sounding. -On 9/27/11, at 1:30 p.m. R65 sustained a bruise under the left eye that measured 1.6 cm X 0.4 cm. after he was found lying on left side on mat next to bed with bed alarm sounding. -On 10/9/11, at 7:40 a.m. R65 was found on mat on floor with alarm sounding. No further falls were identified at the time of the survey. The Fall Assessments and Fall Investigation Worksheets noted prior lacked an assessment and identification of causal and risk factors of R65's falls in order to ensure appropriate interventions had been implemented to try to prevent or minimize further falls/accidents. No new interventions had been attempted following the prior falls. On 10/25/11, at 11:27 a.m. registered nurse (RN)-B stated that R65 had several falls and was a frequent faller. RN-B stated they already had all the available fall interventions in place. On 10/27/11, at 9:09 a.m. RN-B indicated that at the time of R65's first hip fracture (August 2010) she believed the facility had put all needed fall precautions in place. This included the high/low bed, bed and tab alarms and floor mats. RN-B stated, "What else is there?" On 10/27/11, at 11:19 a.m. RN-B stated that interventions including an alarming seatbelt or a pummel or other seating alternative had not been used as they were considered a restraint and they could not use them. RN-B stated she thought a lot of the times R65 was trying to get up because he was just lonely. On 10/28/11, at 11:24 a.m. RN-B and rehab aide (RA)-A were interviewed. RN-B stated stated hip protectors and the tip bars on the wheelchair had been in use had been started for quite awhile and thought it was at least 6 months. During this same time, rehab aide (RA)-A stated that a seating evaluation had been done in the past and they had tried a wedge cushion and a Dycem (anti-slide pad) but this had not been documented. RA-A stated R65 should have a Dycem under the wheelchair cushion and on top of the cushion. RN-B stated she was not aware of this. RA-A stated that something like a pummel for the wheelchair would not be used because they were told it was a restraint. RN-B stated that regarding having the mattress on the floor, she thought this was stopped because he was still crawling out of bed and we just thought it looked better not to have it on the floor. On 10/29/11, at 9:15 a.m. NA-B stated that for measures for fall prevention for R65 the thing to do was to get him into activities and to get him in a crowd. NA-B stated that R65 would not yell out if she sat for 5 minutes with him. NA-B stated, "It does wonders if you got the time and patience" as to helping quiet R65 down. NA-B indicated she thought R65 was lonely a lot of the time. On 10/31/11, at 11:25 a.m. the social worker stated he does the cognitive and mood interviews for the MDS. He stated R65 had been assessed as lonely and this was complicated by his short term memory deficit. The social worker indicated that R65's identified feelings of loneliness had not been assessed in relation to the resident's falls during attempts to get up. R79 had experienced multiple falls without serious injury. Although R79 utilized multiple fall interventions, some of these interventions had been ineffective and possible alternative interventions and adequate supervision had not been implemented. In addition, staff failed to determine if planned fall interventions were actually being implemented. Further, a comprehensive assessment, of the causal factors related to the falls and the pattern of failure and ineffectiveness related to the interventions utilized to prevent falls, was lacking. R79 had [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], indicated R79 had no memory impairment, was independent with daily decision making, but had disorganized thinking. The MDS indicated R79 required extensive assistance with transfers, toilet use, and locomotion and did not walk. The MDS identified R79's impaired balance and a history of falls. The Care Area Assessment (CAA) for falls dated 6/10/11, indicated R79 had falls at home which included a fall that had resulted in a compression fracture and hospital admission. It further identified that R79 had fallen 4 times since admission with no injuries and was receiving physical therapy. Fall interventions for R79 were listed as an alarm on bed and chair and mat on floor. The CAA did not identify monitoring needs to determine if the interventions were appropriate or were actually being implemented or if additional supervision or activities would be effective. The current care plan dated 7/1/11, identified R79's fall risk and directed staff to use mat on floor beside bed, tab alert on bed and chair, bed sensor alarm, bed low to the floor, lap buddy as ordered, cushion in chair, special mattress on bed and to turn and reposition every two hours. R79's care plan directed staff that R79 would inform staff when needing to use toilet for bowel movements and indicated that there was continuous use of a urinary catheter. On 10/26/11, at 7:34 a.m. R79 was observed resting in low bed, mat on floor by bed with bed alarm evident and a rib belt style garment on over his t-shirt. On 10/26/11, at 8:40 a.m. R79 was observed to be positioned in wheelchair without footrests with assist of two NAs and tab alert was placed on wheelchair, alarm clipped to R79. On 10/26/11, at 9:57 a.m. R79 was was observed sitting in wheelchair without footrests and tab alert on. The Fall Investigation Worksheet forms identified R79 had sustained 24 falls without significant injuries between 6/9/11-10/10/11, but lacked reassessment and identification of any interventions to be implemented to try prevent further falls. R79's identified falls were as follows: -On 6/8/11, at 4:00 a.m. R79's bed alarm sounded and was found on the floor. Resident was reported to have had socks on and gripper socks were applied. -On 6/9/11, at 2:00 a.m. R79's was witnessed to slide out of seat of wheelchair while by nurses desk. R79 was identified as experiencing hallucinations or delusions. -On 6/9/11, at 3:10 p.m. R79's chair alarm sounded and was found on floor in the bird room (lounge area) with cushion of wheelchair slipping out of chair. -On 6/11/11, at 7:45 a.m. R79's bed alarm sounded and was found on mat next to bed. R79 stated he "was trying to shut off that damned alarm." -On 6/13/11, at 8:00 p.m. R79's bed and chair alarm sounded and was found on the floor out of low bed. A lap buddy during the evening shift was initiated. -On 6/14/11, at 9:32 p.m. R79's bed alarm and tab alarm sounded and was found on sitting on floor with back against bed. -On 6/19/11, at 11:15 a.m. R79's tab alarm sounded and was found laying in front of the wheelchair. -On 6/22/11, at 2:35 a.m. R79's chair alarm sounded and was found sliding out of wheelchair onto footrests. R79 had taken off the lap buddy. -On 6/24/11, at 1:15 p.m. R79's bed alarm sounded and was found on knees by end of bed stating he had to go to the bathroom. -On 6/27/11, at 4:00 p.m. R79's chair alarm sounded and was found on floor. -On 6/27/11, at 8:00 p.m. R79's bed alarm and chair alarm sounded and was found on sitting on mat at bedside with upper body on bed. -On 6/29/11, at 2:45 p.m. R79's chair alarm sounded and was found on floor next to wheelchair in the dayroom. R79 told a NA that he had slid the floor. -On 7/2/11, at 2:15 p.m. R79's slid out of the wheelchair while in the dayroom. The DON review indicated that R79 would have the lap buddy on at 1:00 p.m. until HS (bedtime). -On 7/27/11, at 9:30 a.m. R 79 was found on footrests with wheelchair tipped forward and chair alarm did not sound. Weights to wheelchair was listed as added intervention. -On 8/5/11, at 3:15 p.m. R79's chair alarm sounded and was found sitting on floor in front of wheelchair with feet out. The DON review indicated that R79 needed to be where he could be watched and that he had "moved very quickly per staff." -On 8/6/11, at 4:20 p.m. R79's chair alarm sounded and was found sitting on foot pedals in front of wheelchair in the day room. -On 8/10/11, at 2:35 p.m. R79's chair alarm sounded and was found slid out of wheelchair on foot rests in the activity area. The DON review indicated that R79 needed to be where people could watch him. -On 8/11/11, at 4:15 p.m. R79's chair alarm sounded and was found laying on the floor in the hall with the wheelchair on top of his legs. A 1.9 cm X 4.1 abrasion and a 8.2 cm X 3.4 cm bruise were noted on the right hip. -On 8/27/11, at 12:45 p.m. R79's chair alarm sounded and was found on knees in front of the wheelchair. The report indicated that the lap buddy had been on and that there was a 1.5 cm X 1 cm abrasion with a 0.4 cm skin tear on the right elbow. -On 9/3/11, at 9:30 p.m. R79's bed alarm sounded and was found laying on mat next to bed. -On 9/19/11, at 10:50 a.m. R79's chair alarm sounded and was found sliding out of wheelchair. -On 10/2/11, at 8:25 p.m. R79's bed alarm sounded and was found on floor on mat by bed. -On 10/5/11, at 4:30 p.m. R79's chair alarm sounded and was witnessed removing his lap buddy. The report indicated that by the time staff reached R79 he was sitting on the floor. -On 10/10/11, at 6:45 p.m. R79's chair alarm sounded and was found on floor in hall out of his wheelchair. No further falls were identified at the time of the survey On 10/26/11, at 2:55 p.m. NA-D stated that the present fall prevention measures in place for R79 were use of a lap buddy, clip alarm, bed alarm, mats and a low bed. NA-D stated that usually if R79 was fidgety he had to have a bowel movement as he received a laxative suppository every other day. On 10/26/11, at 4:45 p.m. the DON stated that the Quality Assurance (QA) committee had reviewed R79's falls on 6/22/11 and the medical director had recommended use of an antibiotic at that time as the resident had a chronic urinary catheter. The DON stated this did reduce R79's falls initially. The DON stated that R79 was more restless in the afternoon so they had added the lap buddy to be on at 1:00 p.m. Additionally, the DON stated they treated the lap buddy as more of a restraint but R79 could remove it and not been injured with the falls. The DON stated most of R79's falls are out of the wheelchair. On 10/28/11, at 11:50 a.m. RN-B and RA-A were interviewed. RN-B stated R79 would scoot to the floor out of the wheelchair and that when he got anxious or "fiddling around" the first thing staff needed to do was ask him if he needed to use the bathroom. RN-B stated this happened especially in the afternoon after dinner and she had thought of having staff toilet R79 around that time but just hadn't gotten around to it. RN-B stated interventions including a pummel were not used because that would have been considered a restraint. RA-A stated that rehab routinely put a scoot guard (Dycem) on top and underneath wheelchair cushions. RN-B stated she was not aware of this intervention or that it needed to be included as a fall prevention measure. With observation of no Dycem in the wheelchair on 10/26/11, with observation of morning cares, RA-A stated that sometimes if the wheelchair or the cushion are dirty and are cleaned, the scoot guard may not get put back in the wheelchair. RA-A stated they did not use pummels in wheelchairs because they were told they were considered a restraint. .