Every finding on record at Harmony Healthcare & Rehab CTR

Based on observation, interview, and record review, the facility failed to implement effective fall precaution interventions for a resident (R2) identified as a fall risk for 1 (R2) of 3 residents reviewed for fall precautions.Findings Include:R2's Facesheet documents that R2 has diagnoses not limited to: unspecified dementia, carcinoma in situ of bladder, essential hypertension, chronic kidney disease, orthostatic hypotension, mild cognitive impairment of unknown etiology, cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, repeated falls, anxiety disorder, unspecified, age related osteoporosis without current pathological fracture, adult failure to thrive, hyperlipidemia, Alzheimer's disease with late onset, anemia, unsteadiness on feet, history of falling.R2's MDS/Minimum Data Set, dated [DATE], documents that R2 does not score on the BIMS/Brief Interview for Mental Status, indicating that R2 is severely cognitively impaired and has memory problems. R2 requires substantial/maximal assistance with Activities of Daily Living (ADL) Assistance and partial/moderate assistance with mobility. R2 is incontinent of bowel and bladder and ambulates via wheelchair.R2's fall care plan documents in part, R2 has at high risk for falls related to impaired mobility, poor safety awareness d/t (due to) episodes of confusion, hx (history) of fall prior to admission, and recent fall. Date Initiated: 09/15/2025. I prefer to keep the bed in the lowest position for safety. Date Initiated: 09/15/2025. I would like staff to provide me a safe environment. Please provide Floor mats/Floor pads at my bedside if appropriate.R2's fall risk assessment dated [DATE] documents that R2 is at high risk for falls with a fall score of 9.R2's fall risk assessment dated [DATE] documents that R2 is at high risk for falls with a fall score of 17.R2's progress note dated 01/14/2026 at 2:15PM documents At around 2:00 PM, resident wheeled to dining room by staff to participate in activities, resident engaged and enjoyed with staff supervision.R2's progress note dated 01/14/2026 at 10:36PM documents At around 6:00 PM, NOD (Nurse on Duty) spoke with Nurse. Resident will be back in the facility. Resident underwent CT scan of the head/neck. 5 stitches was made at the upper left eyebrow.R2's hospital records dated 01/14/2026 documents that R2 was evaluated in the hospital on [DATE] and diagnosed with a laceration to the forehead requiring 5 sutures.R2's progress note dated 01/14/2026 at 12:00AM documents At around 11:30 PM, resident returned back to the facility from emergency room accompanied by 2 ambulance personnel via stretcher. Resident in stable condition, no sign of distress or pain. Head to toe assessment done, noted with 5 sutures to left eyebrow, no active bleeding noted. CT of the head and neck negative with no significant findings. Neurological monitoring in progress, remains at baseline. PRN (as needed) pain medication administered. Writer called son/POA (Power of Attorney) and left a message to provide update. VS checked and recorded BP (Blood Pressure) 150/68 P (Pulse) 75 T (Temperature) 98.1 R (Respirations) 15 SpO2 (Oxygen Saturation) 98% on room air. Resident made comfortable in bed. Kept clean and dry. Bed placed in lowest position, head of bed elevated. Call light within reach. Will endorse accordingly.R2's Facility Reported Incident dated 01/15/2026 documents that R2 fell in the facility and sustained a laceration on the left eyebrow.On 03/08/2026 at 11:12AM, V5 (Registered Nurse/RN) states R2 fell while sitting in the dining room. V5 states she did not witness R2 fall but saw a video on the facility's camera how R2 fell. V5 states it appears from the video that R2 was eating and then became dizzy and fell out of her chair. V5 states she saw on the video that R2 hit her head on the floor and was bleeding. V5 states there were staff members inside monitoring the dining room at that time. V5 states the staff were busy doing other things and was unable to prevent R2 from falling.On 03/08/2026 at 10:35AM, R2 observed located inside the second-floor dining room sitting in a wheelchair. R2 states she fell out of her chair but does not want to discuss the fall. R2 states she does not want to discuss the fall because it was horrible. R2 then states she does not feel well and requests for staff to transport her back to her room.On 03/08/2026 at 11:09AM, surveyor observed R2 in bed. R2's bed in a high position, R2's bed observed to not be in the lowest position. R2 observed in a supine position with head of bed at 45 degrees, R2 noted to be sleeping in bed. R2's bed observed in a high position that reaches surveyor's mid upper thigh measuring approximately 2 feet, 8 inches in height. Surveyor observes that there are no floor mats in place while R2 is in bed.On 03/08/2026 at 12:00PM, V9 (Agency CNA) states she is assigned to care for R2 today. V9 states this is her second time caring for R2 and she is not aware of R2's specific fall precaution interventions. V9 states she is not the person who placed R2 back into bed today. V9 states upon entering R2's room to check on her, V9 noticed that R2's bed was not in the lowest position. V9 states when she checked, R2's bed height reached the middle of her thigh. V9 states from prior experience, she is used to fall risk residents having floor mats in place while in bed. V9 states she started her shift today at 7:00AM and when she arrived, R2 did not have floor mats in place while she was in bed. At 12:05PM, surveyor and V9 now located inside of R2's room. Surveyor observes that R2's bed is not in the lowest position. V9 observed operating R2's bed and lowering R2's bed to the lowest position. R2's bed is now in a position that reaches the middle of surveyor's calf measuring approximately 1 foot in height. V9 states if R2's bed is not in the lowest position and floor mats are not in place, then R2 could fall and injure herself.On 03/08/2026 at 1:23PM, V3 (Fall Coordinator/Restorative Nurse) states she is responsible for inputting the fall interventions into the resident's care plan. V3 states residents' care plans are updated whenever a resident has a fall. V3 states herself, the nurses, and CNA staff are responsible for ensuring that resident's fall interventions are being implemented. V3 states she was made aware that R2 experienced a fall in the facility and was told to go to the dining room. V3 states when she arrived, she saw R2 on the ground and laying on her back. V3 states R2 kept saying, I want to get up. V3 states she observed an injury above R2's left eyebrow. V3 states all fall interventions are expected to be followed once they are put into place for a resident. Surveyor deploys R2's fall care plan on a computer and V3 states R2's care plan does not specify how many floor mats should be in place while R2 is in bed. V3 states the verbiage in R2's care plan pertaining to the floor mats states If appropriate. V3 states she determined that R2 was appropriate to have floor mats in place while in bed. V3 states according to R2's care plan, her bed should be in the lowest position while in bed. V3 states if R2's fall precaution interventions are not implemented, R2 could potentially fall and hurt herself.Facility policy dated 06/30/2025, titled Fall Occurrence documents in part, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Those identified as high risk for falls will be provided fall interventions. The nurse may immediately start interventions to address falls in the unit. The falls coordinator will add the intervention in the residence care plan.

Based on observation, interview and record review the facility failed to ensure that one resident (R3) received the necessary treatment and care for R3 to maintain the highest level of functioning. Failed to identify and treat symptoms of altered cardiovascular status in a patient with CHF, hypertension and stage 3 kidney disease. This failure resulted in R3 having a weight gain of 53.4 pounds, 48% weight gain in 6 months. This failure affected one resident (R3) out of two residents reviewed for death. This failure resulted in R3's hospitalization with a diagnosis of acute decompensated heart failure and diuresing 15 pounds of fluid. Findings include:R3's medical diagnoses include but are not limited to chronic kidney disease, essential hypertension, chronic diastolic heart failure, Alzheimer's disease, shortness of breath, obstructive sleep apnea.R3's Minimum Data Set (MDS) section C dated 07/03/25 has a Brief Interview for Mental Status score of 10 indicating R3's cognition in moderately impaired.R3's Minimum Data Set (MDS) section GG dated 07/03/25 documents in part, C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. 3. Partial/moderate assistance.R3's Minimum Data Set (MDS) section GG dated 08/10/25 documents in part, C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. Dependent.R3's progress note dated 08/09/25 at 10:26pm documents in part, re-admitted following CHF (Congestive Heart Failure) hospitalization (8/5/25). Triggered for significant weight gain of 7.6% in 1 month and 48% in 6 months; weight gain likely fluid-related given CHF/CKD3B (chronic kidney disease) history. Weight trends: 2/4 144.4lbs (pounds), 3/3 148.0lbs, 4/2 150.4lbs, 6/4 169.8lbs, 7/2 185.0lbs, 8/1 203.8.R3's progress note dated 08/05/25 at 08:27am documents in part, Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: Peripheral edema, temporal loss of consciousness. Recommendation: Appearance 1. Summarize your observations and evaluation: Resident was observed with peripheral edema and temporarily loss of consciousness while eating in the dining area. Vital within baseline. Patient back to baseline after loss of consciousness. Resident send out via 911 for further evaluation.R3's progress note dated 07/29/25 at 11:20am documents in part, Internal Medicine Progress Note CC (chief complaint)/Reason for Visit: Weight gain over 55lbs in 6 months. RD (Registered Dietician) follow up; cardiology consulted. History of Present Illness (HPI):. The patient has gained over 55 lbs in the past 6 months, with a current weight of 202.2lbs as of 07/23/25. Nutritional intake has been monitored closely by the registered dietitian and Med Pass BID (twice a day) supplementation is under review. Cardiology consulted for volume status and cardiac contribution. Monitor intake/output, adjust diuretics if needed. Daily weights to monitor trend. Nephrology referral if not already followed. Generalized weakness/Deconditioning. [Daily weights and intake/output were not found in the records reviewed.]Review of R3's physician's orders show order for cardiology consult was not placed until 08/06/25 after R3's change of condition and hospitalization. Review of R3's physician orders show no nephrology consult was ever ordered nor adjustments of diuretics.R3's progress note dated 07/27/25 at 5:19pm documents in part, Nutrition Summary: Resident was discussed during the NAR meeting due to excessive weight gain and concern for fluid retention. Total gain: 55.4lbs over 6 months. Bilateral lower extremity swelling noted at most recent weight. Referred to NP (Nurse Practitioner) for routine lab work to assess renal and metabolic status. Referred to cardiology consult to evaluate fluid status and CHF management. Continue monitoring weight and edema.R3's progress note dated 06/30/25 at 4:25pm documents in part, Reason for visit: Weight gain, increased need for ADL (activities of daily living) assistance, wheelchair bound. Monitor for CHF/CKD signs.R3's hospital record dated 08/10125 documents in part, CXR (chest x-ray) shows cardiomegaly with pulmonary vascular congestion and pulmonary edema. Suspected small right pleural effusion. Pulmonary: Breath sounds; Examination of the right-lower field reveals decreased breath sounds and rales. Examination of the left-lower field reveals decreased breath sounds and rales. Decreased breath sound and rales present. Musculoskeletal: Right lower leg: Edema present. Left lower leg: Edema present.R3's hospital records dated 08/13/25 documents in part, Bilateral pleural effusions and bibasilar atelectasis. Diuresing well with 15lbs weight loss since admission.On 02/11/26 at 2:30pm V8 (Certified Nursing Assistant/CNA) stated that R3 liked sitting in the dining room with her husband and participate in activities. V8 stated that when R3 started gaining weight, R3 was in a lot of pain and had no desire to get out of bed. V8 stated that before R3's weight gain, R3 would notify staff when she needed to use the bathroom and only needed assistance from one staff member. V8 stated that R3 did not like to use the bathroom in adult diapers. V8 stated that after R3 gained weight, R3 became dependent on the use of diapers and could not get out of bed to use the bathroom. V8 stated that she could visually see R3's swelling. V8 stated that R3's whole body was swollen.On 02/17/26 at 11:15am V7 (Registered Nurse/RN) stated that at the beginning of her shift she noticed that R3 edema. V7 stated that when she noticed R3's edema, V7 called to inform the doctor. V7 stated that while on the phone with R3's doctor, the staff informed V7 that R3 had lost consciousness. V7 stated that R3's edema was significant.On 02/17/26 at 12:25pm V14 (Registered Dietician) stated that she remembers R3 having edema with a diagnosis of congestive heart failure and chronic kidney disease. V14 stated that R3's appetite never changed and wasn't the problem causing R3's weight gain. V14 stated that R3's edema was what was impacting R3's weight gain. V14 stated that R3's 48% weight gain was extremely significant and concerning. V14 stated that she never spoke to a physician about R3's weight gain and that she would communicate her concerns to the ADON (Assistant Director of Nursing).On 02/17/26 at 2:42pm V15 (Nurse Practitioner/NP) stated that weight gain started in March of 2025. V15 stated that she wanted R3 to be seen by a cardiologist but appointments take time. V15 stated that R3's weight was always concerning. V15 stated that she assumes that R3 had a functional decline because of the weight gain and the pressure from the weight. V15 stated that R3's excess fluid could affect R3's breathing and refractory period.On 02/18/26 at 1:20pm V18 (Transportation Coordinator) stated that he arranges upcoming doctor's appointments for the residents. V18 stated that the nurses inform him of any appointments that need to be made, and he then schedules them. V18 stated that R3 had no appointments scheduled in July 2025. V18 stated that he was informed to schedule an appointment for R3 on 08/07/25 and that appointment was scheduled for October 2025.R3's physician order dated 08/06/2025 documents in part, Schedule appointment with . MD (medical doctor) ASAP (as soon as possible) in 1 week.R3's care plan dated 01/16/25 documents in part, R3 as potential for renal insufficiency related to kidney disease stage 3. R3 will have no signs/symptoms of complications related to fluid overload. monitor and report changes in mental status, lethargy, tiredness, fatigue, tremors, seizures.R3's care plan dated 01/16/25 documents in part, R3 has altered cardiovascular status related to CHF, hypertension, afib (atrial fibrillation). R3 will be free from signs/symptoms of complications of cardiac problems. Assess for shortness of breath and cyanosis every shift. Monitor/document/report to MD changes in lung sounds on auscultation, edema and changes in weight.Facility's policy titled Weights revised 07/03/25 documents in part, Policy statement: It is the facility's policy to obtain resident's monthly weight unless otherwise ordered differently by the physician. For a resident who is on dialysis, the resident's dry weight will also be obtained monthly. Procedures. 3. The significant weight changes (monthly 5%), quarterly (7.5%), and every 6 months (10%) will be assessed and addressed by the IDT (interdisciplinary team) which includes but not limited to the Dietician, Physician, Medical Specialist, Speech therapist, Nutritionist, and Nurses.Facility's policy titled Medical Appointment revised 07/02/25 documents in part, Policy Statement: It is the policy of this facility to ensure that all resident medical appointments are scheduled on a timely manner in accordance to the physician orders. Procedures: 2. Resident medical appointment shall be approved and ordered by the resident's physician and documented in the resident clinical records.Facility's job description titled RN Floor Nurse dated 12/1/2019 documents in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guest we serve, the Registered Nurse (R.N.) plays a critical role in providing superior customer service and nursing care to all Guest and guest. The RN provides supervision of staff and will safeguard the health, safety and welfare of all Guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: 1. Provides quality nursing care to Guests in an environment that promotes their rights, dignity and freedom of choice.10. Ensure that Guest care plans are being followed and assess each Guest's status in accord with their care plan. 14. Must be knowledgeable of individual care plans and support the care planning process by reporting specific information and observations of the Guest's needs, preferences and report any behavioral change.

Based on interview and record review, the facility failed to access EMS (Emergency Medical Services) for one of one residents (R1) reviewed for change in condition in a total sample of three residents. Findings include: R1's face sheet documents R1 is a [AGE] year-old admitted to the facility on 12.12.2024, with diagnoses including but not limited to: Intrahepatic Bile Duct Carcinoma, Acquired Total Absence of Pancreas, Muscle Wasting and Atrophy, Adult Failure to Thrive, Type 2 Diabetes Mellitus, and Hypertension. R1's MDS (Minimum Data Set of 12.14.2024) documents R1 is moderately cognitively impaired. 1.6.2025, 9:00 PM, General Progress Note documents in part: 3:30 PM- noted resident lying on bed comfortably. No respiratory distress noted. Vital signs taken as follows BP 110/ 64, respiratory rate 20, heart rate 84, oxygen level 92% RA (room air), temperature 98.7, blood sugar 128. Due meds given and well tolerated. At around 5:00 PM, NOD (Nurse On Duty) made a quick round and noted resident verbalized that he feels nauseated. vital signs taken, BP (blood pressure)104/61, HR (heart rate) 97, temperature 100.5, oxygen 89% RA (room air), RR (respiratory rate) 20. The physician was updated and made an order to put resident on oxygen treatment, start an IVF (intravenous fluid) treatment for hydration and STAT (immediate) lab works. At around 5:30 PM, resident's vitals were taken as follows BP 114/ 67, RR 20, HR 91, Temp 98.6, O2 96% via nasal cannula. Resident is easily arousable to tactile stimuli. 1.6.2025, 11:55 PM, General Progress Note documents in part: 11:00 PM, received resident in bed, on moderate high back rest, awake, not in distress, with oxygen inhalation via nasal cannula at 2LPm (liters per minute). Resident denies any discomfort. Vital taken as follows; BP 98/56, HR 92, RR 18, 02 sat-98%. At 11:53 PM NOD (nurse on duty) received chest x-ray result and relayed results to the physician. New orders made and carried out. 1.7.2025, 3:35 AM, General Progress Note documents in part: 1:45 AM, routine rounds made. Resident is alert and sleeping with interval, appear weaker. Vital signs taken as follows: BP 88/ 56, HR-89, RR -17, 02 sat-98%. Placed resident in Trendelenburg position. Physician made aware. Orders made & carried out. At 2:00 AM- vital signs rechecked. BP-68/52, HR-91, RR-18, 02 sat 97% VNC (via nasal cannula). Resident is easily arousable to tactile stimuli. Not in distress. Incontinent care done by staff. Physician made aware and order given to transfer the resident to hospital emergency department. Called (private) ambulance. At 3:15 AM-(Private) ambulance arrived. At 3:28 AM, resident left the facility via stretcher accompanied by 3 paramedics going to (local) hospital ER; remains awake, weakness noted. 1.7.2025, 7:20 AM, General Progress Note documents in part: 7:00 AM- called (local) hospital for follow up but found out that resident was rerouted to (911 hospital) and admitted to MICU (Medical Intensive Care Unit) with diagnosis of septic shock. 1.7.2025, 7:20AM, General Progress Note: 7:00 AM- called local hospital for follow up but found out that resident was rerouted to different hospital and admitted to local hospital with diagnosis of septic shock. 2.22.2025, at 4:09 PM, via telephone, V9 (RN-Registered Nurse) said, I was worried about R1's blood pressure. I don't know why I didn't call 911. I should have, I'm sorry. I think I made a mistake. I did contact V11 (Physician). I think I gave R1 an antibiotic (by mouth), I think I started an IV. His blood pressure was not stable, it kept dropping. I was monitoring him frequently. Yes, septic shock is serious. 2.22.2025, at 4:35 PM, V10 (RN-Registered Nurse) said she checked on R1 at the start of shift; his vital signs were good, he was in no distress. V10 said during med pass, I can't remember what time, he said he was nauseated. I took his vital signs. His blood pressure dropped. He had a fever and his oxygen saturation was 89% on room air. I contacted V11 (Physician) and received orders to put R1 on oxygen, start an IV and obtain STAT labs. I gave him Tylenol for his fever. I continued to monitor him. I would have called 911 and not waited for the private ambulance when his blood pressure dropped. 2.22.2025, at 5:02 PM, via telephone, V11 (Physician) said, I don't remember anything about it (R1). Surveyor read above referenced progress notes to V11. V11 said, I would have sent R1 to the hospital via 911, not a private ambulance, when his blood pressure was below 90. When asked what could possibly happen if access to acute care is delayed, V11 said recovery period could be prolonged, his condition could have worsen if the resident had comorbidities. V11 continued, R1 didn't develop hypoxia because he was awake/alert and coherent. His oxygen level was stable and the resident was stable. 2.22.2025, at 6:03 PM, V3 (ADON-Assistant Director of Nursing) said, V9 (RN-Registered Nurse) was doing close monitoring of R1. R1 was receiving IV fluids and the resident was not in distress. V3 continued, management wise they were able to intervene, but you know the resident came in with stomach cancer. The low blood pressure could be due to the metastatic disease. It seems the blood pressure was stable enough. V3 said constant monitoring was being done though not specified in documentation; it appears the resident stabilized. R1 was still responsive; he could verbalize if he was not doing well. At that time since there were no signs of distress, it was okay during that situation to wait for the private ambulance. Based on the documentation of the nurse, I would have waited for (private ambulance), not called 911.

Based on observation, interview, and record review, the facility failed to ensure residents participated in care planning conferences for 5 (R14, R4, R136, R20, R59) out of 5 residents reviewed in a final sample of 33. Findings Include: On 9/4/24 at 9:52 AM, interviewed R14 and stated admitted in the facility four months ago. R14 stated has not attended any care plan meeting to discuss R14's plan of care. R14's electronic health records show R14 was admitted in the facility on 4/30/24 with diagnoses included but not limited to acute and chronic respiratory failure with hypoxia, dysphagia, major depressive disorder, generalized anxiety, and schizoaffective disorder. R14 had a completed quarterly Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 7/22/24. R14's Brief Interview for Mental Status (BIMS) was coded as 13, which means R14 is cognitively intact. R14's EHR lacked documentation if a care conference was conducted for R14. On 9/4/24 at 9:56 AM, interviewed R136 and stated admitted in the facility two months ago. R136 stated that the facility has not conducted any care plan meeting since R136's admission. R136's EHR shows R136 was admitted in the facility on 5/30/24 with diagnoses included but not limited to chronic obstructive pulmonary, pulmonary hypertension, adult failure to thrive, and emphysema. R136 had a completed admission MDS assessment with ARD of 6/1/24. R136's BIMS was coded as 11 which means R136 has moderately impaired cognition. R136's EHR lacked documentation if a care conference was conducted for R136 since admitted . On 9/4/24 at 10:01 AM, interviewed R4 and stated was admitted in the facility back in December 2023. R4 stated that the last care plan meeting R4 received was four months ago. R4's EHR shows R4 was admitted in the facility on 12/6/23 with diagnoses included but not limited to metabolic encephalopathy, chronic respiratory failure, essential hypertension, type 2 diabetes mellitus, and anxiety disorder. R4 had a completed quarterly MDS assessment with ARD of 8/22/24. R4's BIMS was coded as 12 which means R4 has moderately impaired cognition. R4's EHR lacked documentation if a care conference was conducted for R4. On 9/4/24 at 10:07 AM, interviewed R20 and stated was admitted in the facility one year ago. When asked about a care plan conference R20 attended recently with the interdisciplinary team, R20 stated, I don't think they ever did one. R20's EHR shows R20 was admitted in the facility on 8/23/23 with diagnoses included but not limited to end-staged renal disease, essential hypertension, spinal stenosis, obesity, and type 2 diabetes mellitus. R20 had a completed annual MDS assessment with ARD of 7/3/24. R20's BIMS was coded 10 which means R10 has moderately impaired cognition. R20's EHR lacked documentation if a care conference was conducted for R20. On 9/5/24 at 9:44 AM, interviewed R59 and stated R59 was admitted in the facility in March. R59 stated has not attended any care plan meeting to discuss R59's plan of care. R59 stated, They have not done that with me. R59's EHR shows R59 was admitted in the facility on 3/6/24 with diagnoses included but not limited to dysphagia, malignant neoplasm of pancreas, anxiety disorder, and severe protein-calorie malnutrition. R59 had a completed quarterly MDS assessment with ARD of 6/7/24. R59's BIMS was coded as 12 which means R59 had moderately impaired cognition. R59's EHR lacked documentation if a care conference was conducted for R59. On 9/4/24 at 11:30 AM, interviewed V19 (MDS Coordinator) and stated V19 is responsible in scheduling and sending out invites for the long-term care residents' care plan conferences. V19 stated, We mail the invites to the responsible parties. We verbally invite the residents. Care plan conference are held every quarter. For new admits the social service department schedules it. They are the ones that send invites also. V19 stated V19 is not sure how care plan conferences are scheduled for new admissions. V19 stated normally within 7 days. V19 stated care plan conferences are scheduled and should be held quarterly according to the MDS calendar and as requested. V19 stated care plan conferences should be attended by the interdisciplinary team (IDT) someone from nursing, social worker, dietary, restorative, activity, and therapy if resident is on therapy. V19 stated care plan conferences calendar is emailed and shared to the department heads. V19 stated there are no documentation that the invites are sent. V19 stated all documentation of care plan conference minutes are electronic. V19 stated care plan conference is documented that it was held in the resident's EHR under assessment titled; LCHC-Multidisciplinary Care Conference. V19 stated even if the resident or the family did not attend, care plan conference still should be held with the IDT to discuss the resident's plan of care. Surveyor reviewed R14, R4, R136, R20, and R59's EHR together with V19. V19 confirmed these residents had no documentation indicating care plan conferences were held according to the MDS calendar. V19 stated R14 had MDS in 7/22/24 and should have had a care plan conference in July. V19 stated R4 had MDS completed on 8/22/24 and should have had a care plan conference in August. V19 stated R136 was admitted on [DATE] with the last quarterly MDS review on 8/27/24, but no documentation if R136 had care plan conferences for both the admission and quarterly review. V19 stated R20 had a completed MDS on 7/3/24 and should have had a care plan conference in July. V19 stated R59 had a completed MDS on 6/7/24 and should have had a care plan conference in June. The facility's policy titled; Care Plan Conference dated 7/26/24 reads in part: Resident care conferences are held within the first 72 hours of admission, upon completion of the comprehensive care plan and at least quarterly thereafter in coordination with the MDS schedule and process. Resident / Resident Representative will be invited to the care conference. The care conference is intended to be an interactive meeting with the resident, resident representative(s), and interdisciplinary team representatives to review the care plan, clarify service and contact information, and provide a forum for the resident and/or resident representative(s) to relate satisfaction or dissatisfaction with care. Social Services staff follow up with any complaints or concerns aired during care conference following the facility grievance procedure. Those attending the care conference or participating in the development of the care plan includes but is not limited to the attending physician, a licensed nurse with knowledge of the resident, a nurse aide with responsibility for the resident, a member from dietary, a member of the activity department, a member of the therapy/restorative department, social services personnel, the resident is practicable, the resident's representative if possible. During the care conference the care plan is reviewed with the resident and/or resident's representative.

Based on observation, interview, and record review the facility failed to ensure resident individualized diet order and food plan was followed affecting one resident (R159) out of 6 residents reviewed for nutrition. The facility also failed to ensure the diet spreadsheet and recipes were followed for pureed food preparation affecting all 22 residents receiving pureed diets in the facility's kitchen. Findings Include: On 09/03/24 at 10:41 AM, R159 said, all my meals are pureed, and I get mashed potatoes at almost all my meals which I am really sick of. I don't know why they cannot puree other things for me, so I don't get the same thing every day. R159 stated R159 is not allowed any liquids except water and is only allowed to have ice cream once a day. R159 said, it's because of my swallowing. Sometimes thin liquids go into my lungs instead of into my stomach. On 9/03/24 12:37 PM, observed R159 eating lunch in R159's room. R159 received single portions of pureed pork, what appeared to be mashed potatoes (pureed rice listed on menu), pureed vegetable, ice cream, yellowed colored juice, applesauce, fortified pudding. No water on tray was provided on R159's tray. No gravy was seen on R159's pureed food. Observed R159's meal ticket documented in part, TRIPLE PORTIONS (3X) Food Serving, Fortified Pudding, Applesauce and Only Water for Liquids on Tray. Extra gravy is not listed on meal ticket. R159 stated I should not have been given the juice; I'm only supposed to get water. R159 says R159 gets given cartons of milk, juice, and coffee on R159's meal tray way too often. R159 stated, that juice shouldn't be on my tray. It is a mistake. R159 stated the amount of food R159 received does not look like triple portions to him and that R159 usually only receives single portions. R159 stated R159 usually eats 100% of his meals. On 09/03/24 at 12:56 PM, observed R159's lunch tray. R159 had consumed 100% of all the pureed food on his tray, 100% ice cream, 0% juice, 100% applesauce, 100% fortified pudding. On 09/04/24 at 12:45 PM, observed R159's lunch tray. R159 received singled portions of pureed meat with gravy, pureed green vegetable, pureed bread, mashed potatoes with gravy, fortified pudding, vanilla pudding. There was no water or applesauce on R159's tray. On 09/04/24 at 12:47 PM, surveyor observed with V27 (Certified Nursing Assistant), R64's pureed lunch tray. R64 received single portions of pureed food. On 09/04/24 at 12:50 PM, surveyor observed with V27, R159's pureed lunch tray and V27 stated the portions R159 received looked the same as the portions R64 received. V27 stated R159 did not receive double or triple portions of pureed food. V27 stated V27 gives R159 ice cream after R159 finishes R159's meal because R159 does not like it melted. On 09/04/24 at 12:55 PM, V13 (Registered Nurse) viewed R159's lunch tray and reviewed R159's meal ticket and stated R159 is only allowed water based on R159's meal ticket and R159 should be provided with water on R159's tray. V13 stated R159 was not provided with any water on R159's tray and V13 does not know why it is missing. On 09/04/24 at 12:57 PM, R159 stated, I'm also missing applesauce from my tray which I use because it helps me swallow my food better. R159 looked at the mashed potatoes on R159's tray and stated, see? They gave me mashed potatoes again. Scalloped pureed potatoes sound very good to me. Some variety would be good! R159 stated R159 is not aware of R159 ever being given triple portions and said, that would be a lot of food on my plate and would be something I'd notice. R159 stated R159 usually eats 100% of the pureed food and stated R159 feels R159 could eat more food than is provided to R159. R159 stated the staff always gives R159 ice cream after R159 eats R159's lunch meal. On 09/04/24 at 2:00 PM, V28 (Registered Dietitian) stated the kitchen should be following the menus and recipes to make sure the residents are receiving a variety of food and the appropriate nutrition for the day. V28 stated residents on pureed diets should not receive mashed potatoes every day and today residents on pureed diets should have received pureed scalloped potatoes if that is what the other residents are receiving. V28 stated residents on pureed diets should receive the same items served to residents on regular diet consistency except in a pureed form, assuming the food can be pureed safely. V28 stated the staff should be following the meal tickets and provide the food listed on the meal tickets because the meal tickets list the resident's diet order and any other special instructions specific to that resident. V28 stated based on R159's meal ticket R159 should have received triple portions of pureed foods, applesauce, and water with meals, no juice or other type of liquid. V28 stated it is important to provide R159 with water on R159's tray because this is R159's primary source of water which R159 needs for hydration. V28 stated R159 should not have been provided juice because this has the potential to cause an infection if R159 aspirated the juice. V28 stated R159 should have received applesauce on R159's tray because it is listed on R159's meal ticket. V28 stated R159 is eating well and meeting baseline nutritional needs but if R159 received double or triple portions this could potentially promote weight gain which would be beneficial to R159. On 09/04/24 at 1:18 PM, V29 (Speech Language Pathologist) stated R159 recently had a Modified Barium Swallow Study, and the recommendations were for R159 to stay on pureed diet consistency and with thin water only with meals (no other liquids), one ice cream per day and extra gravy with meals. V29 stated it is safer to aspirate water versus something that is different than what the body normally has inside it compared to the juice which has sugar and coloring in it. V29 stated if R159 aspirated juice it could go into his lungs which could be painful, and water is safer. V29 stated R159 has a very good appetite and when V29 was working with R159 he routinely consumed 100% of the meal. V29 stated applesauce was R159's preference and if R159 feels like the applesauce helps R159 facilitate swallowing then it definitely could and should be provided to R159. V29 stated R159 should not have received the juice on R159's tray and R159 should have received water on R159's tray. V29 stated R159 should be receiving extra gravy with all meals to help the food go down better. On 09/05/24 at 9:57 AM, V31 (Dietary Director) stated the meal tickets reflect the physician generated diet order and any recommendations which come from the Registered Dietitian including food preferences and additional food items. V31 stated it is important for the staff to read the meal tickets carefully to make sure they pick up details of the resident's meal plan. V31 stated it is important for the staff to follow the meal tickets, so the resident receives the correct diet order and dietary interventions based on the physician diet order and Registered Dietitian's recommendations. V31 stated the potential problem of a resident not receiving extra portions when its part of their diet order is that their intake would be lesser than what they should receive for that meal which over time could potentially lead to weight loss. V31 stated R159 should have received triple portions and applesauce as listed on the meal ticket. V31 stated the kitchen staff is not responsible for putting liquids on resident meal trays, that is something the nursing staff does. R159's diagnosis includes but not limited to Pneumonitis Due To Inhalation Of Food and Vomit, Muscle Wasting And Atrophy, Dysphasia Oropharyngeal Phase, Difficulty Walking, Cognitive Communication Deficit, Needs For Assistance Personal Care, Chronic Idiopathic Constipation, Anemia, Severe Protein Calorie Malnutrition, Disorders of Electrolyte and Fluid Balance, Disturbance of Salivary Secretion, Repeated Falls, Cachexia, Reduced Mobility, Specified Disorders Of Bone Density And Structure, Adult Failure To Thrive, Sepsis. R159's MDS (Minimum Data Set) dated 06/14/24 BIMS (Brief Interview for Mental Status) was 12 out of 15 indicating moderately impaired cognition. R159's Order Listing Report printed 09/03/24 documents in part, general diet pureed texture, thin liquids consistency, WATER ONLY. Triple portions with all meals. Applesauce with all meals. Mashed banana with breakfast, extra gravy with meal, may have 1 ice cream per day and fortified pudding with meals for supplementation. R159's meal tickets document in part, general type diet pureed consistency, (3x) TRIPLE PORTIONS food serving applesauce with all meals, ONLY water for liquids on tray. Mashed banana with breakfast and extra gravy with meals are not listed on R159's meal tickets. R159's swallowing/nutrition care plan documents in part, R159 is at risk to potentially choke or aspirate food or liquids. This problem is related to dysphagia. BMI 17.2 underweight. Potential for weight changes due to disease and age process. R159 is malnourished. Interventions include double portions with all meals, applesauce with all meals, pudding with all meals, mashed banana with breakfast when available and prepare/serve the resident's nutritional diet as ordered. 44103 On 9/4/24 at approximately 10:39 AM, Surveyor observed the pureed preparation in the kitchen. V33 (Assistant Cook) pureed the braised beef tips with gravy and the garlic green beans. V33 did not prepare the pureed scalloped potatoes. V33 stated that V33 only prepared the pureed braised beef and the green beans because V33 already prepared the powdered mashed potato from the box, and this will be served to all residents on pureed diet. V33 stated that V33 used the powdered prepacked mashed potato and poured it with boiled water. V33 stated did not put any other ingredients because it's in a pack, just mix the powder with water and its instant mashed potato. V33 stated will not prepare the pureed dinner roll because there is already the mashed potato to be served. V33 and V31 (Dietary Director) stated that the recipe book and the diet spreadsheets are followed when preparing pureed food. V31 further stated that the residents' meal tickets should be followed, and everything listed on the meal ticket should be served to the resident. On 9/4/24, during lunch observation on the 3rd and 4th floors, survey team observed mashed potatoes being served to residents on pureed diet. At 3:07 PM, a follow up visit was conducted in the kitchen and obtained a copy of the Pureed Scalloped Potatoes. V31 stated that V33 added a scalloped seasoning when preparing the powdered mashed potato. Surveyor asked V31 to show the scalloped seasoning that was used. V31 stated it's not available since it was all used up this morning. The facility's Diet Spreadsheet shows for Day: 11 - Wednesday lunch, residents on pureed diet to receive pureed braised beef tips with gravy, pureed scalloped potatoes, pureed garlic green beans, pureed creamy custard pie, pureed buttered dinner roll, and beverage. The facility's Pureed Scalloped Potatoes recipe reads in part: Place prepared scalloped potatoes in a clean and sanitized food processor. Add milk gradually, as needed and blend until smooth. The facility's Diet Type Report printed on 9/5/24 shows there are 22 residents receiving pureed diet in the facility. The facility's job description for the [NAME] dated 12/1/19 shows that it is the Cook's duties and responsibilities to ensure trays are prepared according to diet cards in an efficient manner to meet scheduled meal and snack times.

Based on observation, interview, and record review the facility failed to (a) ensure staff handled medications in a sanitary manner and performed hand hygiene for 4 (R53, R99, R114, R153) of 5 residents reviewed during the medication administration; (b) post Enhanced Barrier Precautions (EBP) signage for 2 (R30 and R64) residents with an indwelling medical device, and (c) wear proper PPE (Personal Protective Equipment) during high contact resident care activities. These failures have the potential to affect 55 residents residing on 3rd floor and 59 residents residing on 4th floor as of census dated 9/3/24. The findings include: On 9/03/24 at 10:18 AM, R30 Observed lying in bed, head of bed slightly elevated, alert with confusion. Observed with IV fluids D5 0.45% NACL infusing on right arm at 40cc/hr. Requested V5 (Registered Nurse / RN) to R30's room, V5 donned gloves and access IV site by removing kerlix wrap to check IV dressing. V5 did not wear gown. No EBP signage posted on room entrance, no PPE supplies available nearby or by the hallway. She said IV fluid was started 3-4 days ago for hydration. At 11:58 am, V7 (Certified Nursing Assistant / CNA) stated has been working in the facility for [AGE] years and regularly assigned on 4th floor. Stated she is working with R30. She said R30 is incontinent of bowel and bladder, requires total assistance with transfer, bed mobility and toileting hygiene. V7 said incontinence care was done earlier and wore gloves. Stated did not wear gown because R30 is not on isolation. At 2:49 pm, Interview with V2 (Director of Nursing / DON) said resident who has foley cath, wounds, G-tube, colonized MDROs, with peripheral line, PICC line, central line, dialysis access site should be placed under Enhanced Barrier Precautions (EBP) and signage should be posted by resident's door so everyone would be alerted when going inside the room. V2 said staff should be wearing proper PPE (Personal Protective Equipment) such as gown, gloves when providing high care activities such as accessing IV site, providing incontinence care, ADL (activities of daily living) care. Wearing proper PPE is for staff and resident protection to prevent cross contamination. PPE supplies should be available at least 2 rooms apart. On 9/5/24 at 11:35 am, V3 (Infection Preventionist / IP nurse) said has been working in the facility for a year. Residents who have indwelling medical devices such as IV access site, central line and dialysis access site, wounds should be placed under EBP. Signage kept in front of the door; PPE supplies keep in bins shared in between every 2 -3 resident's rooms. She said EBP signage is posted so staff is aware that resident is on EBP in that room and instructions of PPE requirements, when to put it on. High contact activities / care such as changing bed, linens, incontinence care and IV dressing. Staff should be wearing proper PPE such as gloves and gown and mask if needed. V3 said if staff is not wearing proper PPE, could potentially Introducing possible infection to the residents. Protection for staff and residents. MDS (minimum data set) dated 6/3/24 showed R30's cognition was severely impaired. She needed substantial / maximal assistance with eating, oral and personal hygiene, shower / bathe self, upper body dressing, Dependent with toileting hygiene and lower body dressing. MDS showed R30 was incontinent of bowel and bladder. R30's POS (physician order sheet) showed active order not limited to: Dextrose - NaCl solution 5-0.45% (Dextrose - Sodium Chloride) use 40ml/hr intravenously every shift for hydration for 3 days. Order date 8/31/24. Facility's policy for Enhanced Barrier Precaution dated 7/26/24 documented in part: EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high contact resident care activities for residents known to be colonized or infected with MDROs as well as residents with wounds and / or indwelling medical devices. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of XDROs to staff hands and clothing. Examples of high contact resident care activities requiring gown and gloves use among resident s that trigger EBP use include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care use. 39779 On 09/03/24 at 09:17 AM, V13 (Registered Nurse) entered R153's room with signage posted Enhanced Barrier Precautions with the blood pressure monitor obtaining a blood pressure reading of 114/71 pulse 74. V13 exited R153's room without performing hand hygiene and began preparing R153 medications. On 09/03/24 at 09:24 AM, V13 (Registered Nurse) entered R153's room and administered R153 medications. On 09/03/24 at 09:31 AM, V13 (Registered Nurse) entered R114's room with signage posted Enhanced Barrier Precautions and assisted R114 with dressing. V13 exited R114's room without performing hand hygiene and began preparing R114 medications. V13 reentered R114's room to administer R114's medications. On 09/03/24 at 09:37 AM, V13 (Registered Nurse) returned to the medication cart to document in the computer without performing hand hygiene. V13 then put on gloves and began cleaning the blood pressure monitor. On 09/03/24 at 09:39 AM, surveyor asked V13 (Registered Nurse) what she should have done after obtaining R153's blood pressure, before preparing R153 medication, after assisting R114 with dressing, before preparing R114's medications and before applying gloves to clean the blood pressure monitor. V13 responded, hand sanitizing. I used gloves, but it is for infection control. On 09/03/24 at 09:46 AM, V12 (Registered Nurse) proceeded down the hallway and pushed R53 in her wheelchair to her room. V12 returned to the medication cart and began preparing R53's medications without performing hand hygiene. On 09/03/24 at 09:50 AM, V12 (Registered Nurse) entered R53's room and administered R53's medication. V12 retrieved the medication cup, placed R53's call light closer to her, returned to the medication cart, and discarded the medication cup. On 09/03/24 at 09:54 AM, V12 (Registered Nurse) entered R99's room with signage posted indicating Enhanced Barrier Precautions with the blood pressure monitor obtaining a blood pressure reading of 133/65 pulse 75. On 09/03/24 at 10:01 AM, V12 (Registered Nurse) returned to the medication cart without performing hand hygiene then began preparing R99's medications. V12 reentered R99's room and administered R99's medications. V12 then exited R99's room without performing hand hygiene, retrieved a pair of gloves then reentered R99's room and repositioned R101 in the bed. On 09/03/24 at 10:05 AM, surveyor asked V12 (Registered Nurse) what she should have done after pushing R53 in the wheelchair and before preparing R53 medications. V12 responded, Hand hygiene, wash or do something to prevent any cross infection. When asked should hand hygiene be done before applying gloves, V12 responded, technically if my hands are clean, I would not do it. When asked after administering medication and touching the medication cup that the resident took the medication cup would her hands be considered unclean. V12 responded, yes, they would be contaminated. When asked are gloves used as a substitution for hand hygiene. V12 responded, gloves are not used as a substitute for hand hygiene. Hand hygiene should be done before the gloves are applied. On 09/05/24 at 12:06 PM, V2 (Director of Nursing) stated when staff is passing medications at the beginning and completion of the task, hand washing or hand hygiene with the sanitizer should be done. After touching the wheelchair, the nurse hands were contaminated, and she should have done hand washing or sanitizing before preparing the medication. After touching the blood pressure monitor, the nurse should have washed her hands before preparing the medication. That is standard precautions for infection control. The nurse should have washed her hands before applying the gloves and repositioning R101. Gloves are not used as a substitution for hand hygiene. Always hand washing then gloves. Before and after resident contact hand hygiene should be performed. Policy: Titled Medication Pass revised 08/16/24 document in part: Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. 7. PO (by mouth) meds: a. Follow hand hygiene procedure before and after each resident. Titled Hand Hygiene revised 07/30/24 document in part; Policy Statement: Hand hygiene is important in controlling infections. Hand Hygiene consists of either hand washing or the use of alcohol gel. The facility will comply with the CDC (Centers for Disease Control and Prevention) Guidelines in regard to hand hygiene. Procedures 1. Hand Hygiene using alcohol-based hand rub recommended during the following situations: a. Before and after direct resident contact. i. after removing gloves including during wound dressing change. 46342 On 09/03/24 at 11:03 AM, observed tube feeding pole at R64's bedside with no tube feeding hung or infusing. There was no Enhanced Barrier Precaution (EBP) signage posted outside R64's room. On 09/03/24 at 11:11 AM, V13 (Registered Nurse) stated residents on Enhanced Barrier Precaution include those who have any indwelling catheter for urinary, feeding tube, central line or open wounds. V13 stated Enhanced Barrier Precaution signage is posted outside the resident's room to give a visual alert to staff and visitors so they know to do hand hygiene before and after entering the room or wear personal protective equipment (PPE) when administering care. V13 stated R64 has a gastrostomy tube and R64's tube feeding is administered at night. On 09/03/24 at 12:19 PM, V13 looked in R64's electronic health record (EHR) and stated R64 has a physician order for Enhanced Barrier Precaution dated 09/02/24. V13 observed that there was no Enhanced Barrier Precaution sign outside R64's room and stated V13 does not know why there is no Enhanced Barrier Precaution sign outside R64's door. V13 stated R64 should have an Enhanced Barrier Precaution sign posted outside R64's room because R64 has a gastrostomy tube. On 09/03/24 at 12:21 PM, observed V13 posting Enhanced Barrier Precaution sign outside R64's room on R64's door. V13 stated, V13 called the Infection Preventionist Nurse who told V13 to post the EBP sign outside R64's room. On 09/05/24 at 9:40 AM, V2 (Director of Nursing) stated if a resident has a feeding tube there should be Enhanced Barrier Precaution signage outside the resident's door to tell the staff what type of PPE to wear and when to where it. V2 stated the potential problem if there is no EBP signage on the resident's door is the staff may not know to wear PPE when providing care which would be an infection control concern because of the potential for cross contamination. On 09/05/24 at 10:22 AM, V3 (Infection Preventionist Nurse) stated V3 is the one who reviews all new admissions to see if they require contact isolation. If a resident has an indwelling catheter or open wound(s) they are placed on Enhanced Barrier Precautions. V3 stated V3 is responsible for putting up the Enhanced Barrier Precaution sign outside the resident's room. V3 stated the purpose of putting up the Enhanced Barrier Precaution sign is to notify the staff what PPE they have to wear when providing direct care to the resident and alert visitors to do hand hygiene before/after entering the room. V3 stated the potential problem if the Enhanced Barrier Precaution sign is not posted outside the resident's room who required EBP is that the staff would not know to put on PPE for high contact care activities and therefore there would be an increased risk of the resident getting an infection from the staff. V3 stated V3 put in an order into R64's EHR on 09/02/24 for Enhanced Barrier Precaution when V3 found out R64 was receiving tube feedings. V3 stated R64 should have had an Enhanced Barrier Precaution sign posted outside R64's room because R64 has a feeding tube. V3 stated, it was an oversight. R64's diagnosis included but not limited to Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting Right Dominant Side, Dysphasia, Aphasia, Encounter for Attention to Gastrostomy, Difficulty in Walking, Abnormalities of Gait Mobility, Cognitive Communication Deficit, Muscle Wasting and Atrophy, Need For Assistance With Personal Care, Type 2 Diabetes Mellitus, Long Term Use Of Insulin, Encephalopathy, Malignant Neoplasm Of Unspecified Part Of Unspecified Bronchus Or Lung, Cerebral Infarction, Depression, Asthma, Chronic Pain, Gastroesophageal Reflux Disease Without Esophagitis, Osteoarthritis Left Knee, Spinal Stenosis, Intervertebral Disc Degeneration, Hyperlipidemia, Hypertension, Hypertensive Heart Disease With Heart Failure, Radiculopathy. R64's Order Summary Report dated 09/03/24 documents in part enteral feeding order dated 08/03/24 Nepro 75 ml per hour, on at 4 PM, off at 8 AM and Enhanced Barrier Precaution: Enteral feeding tube every shift dated 09/02/24. R64's MDS (Minimum Data Set) from 08/05/24 documents in part, BIMS (Brief Interview for Mental Status) score is 0 (could not be conducted) resident is rarely/never understood indicating severely impaired cognition, and nutritional approaches include feeding tube and the proportion of total calories the resident is receiving through tube feeding is 51% or more. R64's infection control care plan dated 09/02/24 documents in part, (R64) is on Enhanced Barrier Precaution for enteral feeding tube.

Based on observation, interview, and record review, the facility: failed to ensure staff did not stand while feeding 2 (R34, and R95) residents that are dependent on staff for assistance with eating and Failed to treat one resident (R417) with respect and dignity by not passing out meals to all residents sitting at the same table at the same time during dining observation in a sample of 33. Findings include: 1. R34's face sheet documents in part; medical diagnoses including but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Dysphagia, Acute Cough, and other Seizures. R34's physician orders sheet document in part; R34 requires total assistance with meals, strict aspiration precautions. On 09/03/24 at 12:24 PM, R34 was in bed with head of the bed elevated. R34's bed was close to the floor, and there was a chair at R34's bed side. V24 (Restorative Aide) stood on R34's right side and fed R34. V24 was standing and not at eye level with R34. V24 stated that V24 forgot to sit, and that V24 should be seated to feed R34 to keep R34 at eye level and to prevent R34 from choking. On 09/04/24 at 11:17 AM, V26 (Certified Nursing Assistant/CNA) stated when a resident is in bed or up in chair, the staff should be sitting at eye level when feeding the resident, and to prevent the resident from choking. On 09/05/24 at 10:48 AM, V2 (Director of Nursing) stated, if a resident is dependent on assistance with eating, the staff need to sit with the resident while providing feeding assistance to provide eye level contact for proper observation, to prevent choking and V2 stated it is a dignity issue which should be respected. Facility's Privacy and Dignity policy, last revised 8/16/24, documents in part: It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times. Surveyor also reviewed facility's Restorative Nursing Program policy, last revised 8/19/24. No procedures on how to maintain a resident's dignity during meal assistance. 39779 2. R95 has diagnosis not limited to Congenital Kyphosis, Thoracic Region, Gastro-Esophageal Reflux Disease, Essential (Primary) Hypertension, Unspecified Protein-Calorie Malnutrition, Unspecified Dementia, Unspecified Severity, with Agitation, Restlessness and Agitation, Schizoaffective Disorder, Mood [Affective] Disorder, Hyperlipidemia, Alzheimer's Disease, Syncope and Collapse and Rectal Prolapse. R95's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) document 0, resident is rarely/never understood. R95's meal ticket document in part: Food tray set up, (Partial Feeding Assist). On 09/03/24 at 12:35 PM, R95 was observed sitting in a chair in the fourth-floor dining room with a lunch tray in front of her. There was a general mechanical soft meal that contained vegetables, ground meat on a bun, a chocolate ice cream cup and juice. V16 (Activity Aide) was observed standing next to and feeding R95. After V16 was observed standing feeding R95 a staff member brought a chair for V16 to sit in. V16 then sat in the chair next to R95 and continued to provide feeding assistance to R95. On 09/03/24 12:47 PM, V18 (Memory Care Director) was observed standing on R95's right side attempting to feed R95. Surveyor asked V18 the reason for standing next to R95 feeding her. V18 responded, I was encouraging R95. On 09/05/24 at 12:06 PM, V2 (Director of Nursing) stated when feeding a resident, it is common sense to maintain eye contact you have to sit down and maintain a level to see the resident reaction, for social interaction, how the resident eats and dignity with the resident. 47304 3. On 9/3/24 at 11:53 AM, R417 observed sitting up on wheelchair waiting for lunch tray. She is seated at the same table with R94, R135 and R158. At 12:18pm, R135 was served a meal tray. Lunch tray with rice, ground meat, and mixed vegetables, coffee and juice. She is able to spoon feed self post tray set up. At 12:19pm, Meal tray was served to R158. Lunch tray with rice, ground meat and mixed vegetables. She can spoon feed self post tray set up. At 12:21pm, Meal tray was served to R94. Lunch tray with Rice, 2 eggrolls, mixed vegetables, coffee, juice. R94 can feed self post tray set up with good appetite. At 12:48pm, Surveyor asked V7 (Certified Nursing Assistant / CNA) and stated R417 did not eat lunch yet, they are following up meal ticket to the kitchen and meal will be provided. At 12:50pm, Lunch tray was served to R417, other 3 residents (R94, R135 and R158) seated in the same table with R417 had finished eating already. R94, R135 and R158 with good appetite, consumed almost 100% of the food served. At 2:49pm, V2 (Director of Nursing / DON) said staff are expected to serve meal tray almost at the same time for those residents seated at one table. It is dignity issue if residents at the same table are almost done eating and another resident is not eating and waiting for meal tray. On 9/4/24 at 10:45am, V1 (Administrator) stated we don't have a policy for meal tray distribution, but it is a best practice that people sitting at the same table should be served at the same time. To ensure that no one is looking at someone else's food and wishing they had food to eat. Facility's policy for privacy and dignity dated 8/16/24 documented in part: It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times.

Based on observation, interview, and record review the facility failed to determine self-administration of medication was appropriate for one resident (R70) in a sample of 33. Findings include: R70's face sheet documents in part medical diagnoses including but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, flexion deformity left fingers joints, pain in left fingers, and adult failure to thrive. R70's Minimum Data Set (MDS) dated [DATE] shows R70 is moderately cognitively intact. On 09/03/24 at 10:48 AM, surveyor observed Lidocaine 4% External Analgesic Cream on R70's bed side table. R70 stated one of the nurses gave R70 the Lidocaine cream couple of months ago for R70's left finger pain. R70 stated R70 uses the cream every other day, and R70 had used the cream this morning. On 09/03/24 at 2:53 PM, interviewed V12 (Registered Nurse/RN) who stated that all medications must have a doctor's order, and no medication either over the counter (OTC) or prescription should be kept at the bed side. V12 stated there should be an order for self-administration. On 09/03/24 at 3:40 PM, when V23 (Licensed Practical Nurse/LPN) was asked if medication should be kept at bed side. V23 stated no medication should be placed at bed side without doctor's order. V23 stated Normally, we are supposed to get an order for the resident to self-administer medicine. V23 stated that R70 did not have an order to self-administer the medication. V23 stated the potential problem is that any confused resident can walk into R70's room to swallow the medication, R70 can overdose the medication, and it is a safety issue. On 09/03/24 at 3:47 PM, V2 (Director of Nursing/DON) stated that for medication administration, the nurse is expected to complete hand hygiene, check the five rights before administering any medications. V2 stated it is V2's expectation that nurses will not leave any medication at bed side without a doctor's order. V2 stated that the potential problem is medication error, other resident could take wrong medication, and could cause medical problem. On 09/03/24 at 3:50 PM, R70's Physician Order Sheet (POS) with active order as of 9/3/24 shows no order for self-administration of Lidocaine 4% cream and to keep medication at bed side. R70's electronic health record (EHR) was reviewed, no Medication Self-Administration Evaluation Form was completed. Review of Medication Pass policy revised 8/16/24. Policy statement: It is the policy of the facility to adhere to all federal and state regulations with medication pass procedures. Review of Self-Administration of Medication policy revised 6/2/24, states: The resident may store the medication at bedside if there is a physician order to keep it at bedside. Policy Statement: A resident who requests to self-administer medications will be assessed to determine if resident is able to safely self-medicate. Procedure 1. The IDT will assign a staff to evaluate resident's ability to safely administer medication. A self-administration evaluation will be filled out to determine capability. A return demonstration will be done to accurately evaluate resident's ability after the health teaching.

Based on interview and record review the facility failed to obtain a Physician order and update the resident record with the correct code status for 1 (R85) resident reviewed for Advance Directives in a sample of 33. Findings Include: R85 has diagnosis not limited to Primary Osteoarthritis, Right Ankle and Foot, Alzheimer's Disease with Late Onset, Type 2 Diabetes Mellitus, Hyperlipidemia, Essential (Primary) Hypertension, Nontoxic Single Thyroid Nodule, Chronic Kidney Disease, Stage 3, Dementia, Long Term (Current) use of Oral Hypoglycemic Drugs, Long Term (Current) use of Insulin, Primary Generalized (Osteo) Arthritis, Cerebral Infarction due to Thrombosis of Right Middle Cerebral Artery, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Major Depressive Disorder, Hypothyroidism, Long Term (Current) use of Anticoagulants, Localized Edema, Anxiety Disorders, Muscle Wasting and Atrophy, Need for Assistance with Personal Care, Difficulty In Walking and Abnormalities of Gait and Mobility. R85's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) document 04 indicating cognitive function as severely impaired. On [DATE] at 10:29 AM, surveyor asked V14 (Registered Nurse) R85's code status. V14 looked in the computer. V14 stated R85 has no code status. Let me check. V14 called admissions/social service and asked can they check the code status for R85 because it's not there. The surveyor asked V14 to print R85's face sheet and physician orders prior to making any changes. The surveyor then asked V14 if a resident was observed unresponsive without a code status what would be done. V14 responded, If I observed the resident with no code status unresponsive and they needed CPR (Cardiopulmonary Resuscitation) I still have to assess the resident. I understand you need that code status, and it is very important. It is still my judgement if the resident does not have the Do Not Resuscitate POLST (Physician Order for Life Sustaining Treatment) form. On [DATE] at 10:39 AM, V4 (Social Service Director) arrive to the fourth floor and stated there is no code status order for R85 at the moment. The code status is usually just on the POS (Physicians Order Sheet) if they are a full code or Do Not Resuscitate. The responsibility for the code status would be conjoined between social service and nursing to make sure the POS matches the care plan. If there is no code status that would be an error on our part, that we did not audit. It may have been from a readmission, and it was not caught that the code status was not in place. On [DATE] after V14 (Registered Nurse) spoke to V4 (Social Service Director) and V14 was instructed by V4 to enter the physicians order for R85's code status. V14 entered R85's physician order for the code status of Full Code then printed R85's Face Sheet and Physicians Order to reflect R85' code status as Full Code. On [DATE] at 12:06 PM, V2 (Director of Nursing) stated Advance directives for the patient are the DNR (Do Not Resuscitate) status and we call the doctor for the order. Surveyor asked V2 the policy for Advance Directives. V2 stated, we always presume if a resident is a full code, they do not have to have an order. R85's care plan was not updated because there was no change of code status, that is what I am presuming. If a resident needs CPR (Cardiopulmonary Resuscitation) the first thing the nurse does is go to the computer, the POLST (Physicians Order for Life Sustaining Treatment) binder is the back up if the computer is down. If a resident is admitted to the hospital all the orders are discontinued. When the resident is readmitted , the nurse has to get new orders and look at the discharge orders from the hospital. The care plan is focused on the physician orders and the resident needs. The care plan and the physician orders should match. Care Plan document in part: Focus: Advance Directives - R85 has appointed her POA (Power of Attorney) of healthcare and he wishes for R85 to remain a full code at this time. Date Initiated: [DATE]. Interventions: All staff will be made aware of the resident's wishes related to Advance Directives Date Initiated: [DATE]. Review directives with family as needed. Document titled Order Details dated [DATE] at 10:39 document in part: Order Type: Advance Directives. Order Summary: Full Code Document titled Order Listing Report document in part: R85's Full Code Status dated [DATE]. Policy: Titled Advance Directives revised [DATE] document in part: 5. Appropriate information will be added to Physician Order Sheet (POS). 6. The resident's Advance Directive choices/options shall be reviewed during the reassessment and quarterly care planning process. 7. Discussion of Advance Directives and treatment options/refusals will be addressed in appropriate chart documentation as well as care planning during the admission process, as indicated. Review of Advance Directives: 1. Advance Directive information shall be reviewed periodically during the resident's stay, but no less than once a year.

Based on interview and record review the facility failed to ensure a resident's Advance Directives care plan was revised after three hospitalization s and readmissions to the facility for 1 (R85) resident reviewed for Advance Directives in a sample of 33. Findings Include: R85 has diagnosis not limited to Primary Osteoarthritis, Right Ankle and Foot, Alzheimer's Disease with Late Onset, Type 2 Diabetes Mellitus, Hyperlipidemia, Essential (Primary) Hypertension, Nontoxic Single Thyroid Nodule, Chronic Kidney Disease, Stage 3, Dementia, Long Term (Current) use of Oral Hypoglycemic Drugs, Long Term (Current) use of Insulin, Primary Generalized (Osteo) Arthritis, Cerebral Infarction due to Thrombosis of Right Middle Cerebral Artery, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Major Depressive Disorder, Hypothyroidism, Long Term (Current) use of Anticoagulants, Localized Edema, Anxiety Disorders, Muscle Wasting and Atrophy, Need for Assistance with Personal Care, Difficulty In Walking and Abnormalities of Gait and Mobility. R85's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) document 04 indicating cognitive function as severely impaired. Care Plan document in part: Focus: Advance Directives - R85 has appointed her POA (Power of Attorney) of healthcare and he wishes for R85 to remain a full code at this time. Date Initiated: [DATE]. Interventions: All staff will be made aware of the resident's wishes related to Advance Directives Date Initiated: [DATE]. Review directives with family as needed. R85 was admitted to the facility on [DATE]. R85 was hospitalized three times on [DATE], readmitted [DATE], [DATE] readmitted on [DATE] and [DATE] readmitted [DATE]. On [DATE] at 10:29 AM, surveyor asked V14 (Registered Nurse) R85's code status. V14 looked in the computer. V14 stated R85 has no code status. Let me check. V14 called admissions/social service and asked can they check the code status for R85 because it's not there. The surveyor asked V14 to print R85's face sheet and physician orders prior to making any changes. The surveyor then asked V14 if a resident was observed unresponsive without a code status what would be done. V14 responded, If I observed the resident with no code status unresponsive and they needed CPR (Cardiopulmonary Resuscitation) I still have to assess the resident. I understand you need that code status, and it is very important. It is still my judgement if the resident does not have the Do Not Resuscitate POLST (Physician Order for Life Sustaining Treatment) form. On [DATE] at 10:39 AM V4 (Social Service Director) arrive to the fourth floor and stated there is no code status order for R85 at the moment. The code status is usually just on the POS (Physicians Order Sheet) if they are a full code or Do Not Resuscitate. The responsibility for the code status would be conjoined between social service and nursing to make sure the POS matches the care plan. If there is no code status that would be an error on our part, that we did not audit. It may have been from a readmission, and it was not caught that the code status was not in place. On [DATE] after V14 (Registered Nurse) spoke to V4 (Social Service Director) and was instructed to enter the physicians order for R85's code status by V4, V14 entered then printed R85's Face Sheet and Physicians Order to reflect R85' code status as Full Code. On [DATE] at 12:06 PM, Surveyor asked V2 (Director of Nursing) the policy for Advance Directives. V2 stated, we always presume if a resident is a full code, they do not have to have an order. R85's care plan was not updated because there was no change of code status, that is what I am presuming. If a resident is admitted to the hospital all the orders are discontinued. When the resident is readmitted , they have to get new orders and look at the discharge orders from the hospital. The care plan is focused on the physician orders and the resident needs. The care plan and the physician orders should match. Document titled Order Details dated [DATE] at 10:39 document in part: Order Type: Advance Directives. Order Summary: Full Code Document titled Order Listing Report document in part: R85's Full Code Status dated [DATE]. Policy: Titled Advance Directives revised [DATE] document in part: 5. Appropriate information will be added to Physician Order Sheet (POS). 6. The resident's Advance Directive choices/options shall be reviewed during the reassessment and quarterly care planning process. 7. Discussion of Advance Directives and treatment options/refusals will be addressed in appropriate chart documentation as well as care planning during the admission process, as indicated. Review of Advance Directives: 1. Advance Directive information shall be reviewed periodically during the resident's stay, but no less than once a year. Titled Care Plan revised [DATE] document in part: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. A comprehensive care plan must be developed after the comprehensive assessment of the resident. 5. These will be periodically reviewed and revised by a team of qualified person after each assessment.

Based on observation, interview and record review the facility failed to ensure oxygen tubing was properly labeled for 1 (R136) resident, and to ensure residents received the correct oxygen flow rate as ordered by the physician for 2 (R50, R136) out of 2 residents reviewed for respiratory care. Findings Include: 1. On 9/3/24 at 10:51 AM, R136 was lying in bed alert and able to verbalize needs. R136 was using oxygen via nasal cannula. R136's oxygen concentrator flow rate was set to 3.5 liters per minute (LPM). R136's oxygen tubing was not labeled when it was last changed. R136 stated R136 has Chronic Obstructive Pulmonary Disease (COPD) and nursing staff sets R136's oxygen. R136 denied changing the flow rate of the oxygen concentrator. At 10:53 AM, interviewed V21 (Registered Nurse) and stated oxygen tubing is changed weekly and as needed. V21 stated oxygen tubing is supposed to be labeled to let the staff know when it was last changed. V21 stated R136 is supposed to be getting oxygen at 3LPM continuously. R136's electronic health records show R136 was admitted in the facility on 5/30/24 with diagnoses included but not limited to chronic obstructive pulmonary, pulmonary hypertension, adult failure to thrive, and emphysema. R136's Minimum Data Set (MDS) dated [DATE] shows R136 has moderately impaired cognition. R136's physician order reads in part: Oxygen 3L/min continues for CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION. R136's care plan date initiated on 6/3/24 reads in part: Give oxygen as ordered by the physician at 3LPM continuously. On 9/3/24 at 2:41 PM, interviewed V2 (Director of Nursing) and stated that it is the facility's policy to change the oxygen tubing weekly and as needed. V2 stated nurses must label the tubing when it was changed. V2 stated the purpose for that is for infection control that it's changed timely when it's supposed to be. V2 stated, nurses must follow the physician's order when administering the oxygen and should monitor the residents' oxygen that it's on the correct setting. The facility's policy titled; Oxygen Therapy and Administration dated 8/16/24 reads in part: Oxygen therapy shall be administered to patients as indicated and upon a physician's order. Confirm order from physician. Assemble equipment as needed. Date your equipment. Oxygen setups should be changed every seven days and as needed if heavy soiling is present. 46342 2. On 09/03/24 at 11:02 AM, observed R50 sleeping in bed with oxygen infusing per nasal cannula. Observed oxygen concentrator infusing at 3.5 liters per minute. On 09/03/24 at 11:23 AM, with surveyor V13 (Registered Nurse) observed R50's oxygen infusing rate and stated, it's set at 3.5 liters per minute. V13 then went to medication cart and looked up R50's oxygen order in R50's electronic health record (EHR). V13 stated R50's order is for 2 liters per minute PRN. V13 stated V13 does not know how the oxygen rate got up to 3.5 liters per minute because when V13 checked R50's rate earlier this morning it was set at 2 liters per minute. V13 stated R50 cannot reach the oxygen concentrator so R50 could not have changed the rate. V13 stated the rate should not be that high based on the doctor's order, it should be infused at 2 liters per minute. On 09/03/24 at 11:27 AM, V13 checked R50's oxygen saturation rate which was 99%. V13 turned down R50's oxygen rate to 2 liters per minute. R50's diagnosis included but not limited to Cerebral Infarction, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hyperlipidemia, Peripheral Vertigo Unspecified Ear, Hearing Loss Bilateral, Tinnitus, Unspecified Ear, Hypertension, Cerebral Infarction Due To Unspecified Occlusion Or Stenosis Of Basilar Artery, Cerebral Infarction Due To Unspecified Occlusion Or Stenosis Of Unspecified Cerebral Artery, Asthma, Dysphasia, Dizziness And Giddiness, Syncope And Collapse, Long Term Use Of Insulin, Acquired Claw Hand, Left Hand R50's Order Listing Report dated 09/03/24 documents in part, oxygen 2L/min via nasal cannula to maintain oxygen saturation level equal or above 92% as needed for asthma. R50's oxygen care plan dated 09/03/24 documents in part, give oxygen as ordered by the physician at 2 LPM (liters per minute) via nasal cannula.

Based on observation, interview, and record review, the facility failed to ensure adaptive eating equipment was provided to 2 (R96 and R135) residents to facilitate self-feeding. This failure affected 2 (R96 and R135) of 2 residents reviewed for assistive device during mealtime in the sample of 33 residents. The findings include: R96's admission record documented admitted on 10/21/2023 with diagnoses not limited to Parkinson's disease without dyskinesia, Difficulty in walking, Alzheimer's disease, Unspecified dementia, Adult failure to thrive, Anemia, Presence of cardiac pacemaker. R135's admission record documented admitted on 6/7/2023 with diagnoses not limited to Huntington's disease, Adjustment disorder with depressed mood, Dysphagia, Anemia, Unspecified dementia. On 9/3/24 at 12:18 PM, During dining observation, R135 sitting up on wheelchair in the dining room. Lunch tray served with divider plate with rice, ground meat, mixed vegetables, juice, coffee. R135 observed with involuntary movements, able to spoon feed self post tray set up. R135 wearing protective clothing with food spillage on it. R135's meal ticket showed Divider plate to use + adaptive utensils (silver wares with rubber handles). Adaptive utensil was not provided at mealtime. R135 was using regular silver with no rubber handles and food was falling / spilling on her protective clothing. V5 (Registered Nurse / RN) requested to the dining room and confirmed adaptive utensil was not available for R135. V5 said she will follow up in the kitchen. At 12:33 PM, R96 observed sitting up on wheelchair in the dining room. Lunch tray served with divider plate with rice, ground meat, mixed vegetables. Observed R96 feeding self and having difficulty scooping out food. Observed spillage of food on lunch tray and clothing. Meal ticket indicated plate guard, but no plate guard was provided. On 9/3/24 at 2:49 pm, V2 (Director of Nursing / DON) said adaptive eating equipment is recommended by therapist. Kitchen is responsible for providing and cleaning the equipment. Adaptive eating equipment helps or assist resident during mealtime, maintain level of functioning and promote independence at mealtime. On 9/4/24 at 10:50 am, V11 (Director of Therapy) said has been working in the facility about 2 years. Adaptive eating equipment is recommended by OT (Occupational Therapist) to promote independence at mealtime. He said example of adaptive eating equipment is weighted utensil and plate guard. Weighted utensil is recommended for resident who have tremors, easier for the resident to bring food into their mouth to prevent spillage of food and better control from hand to mouth. It will provide more independence with eating. Possible more spillage of food when eating adaptive equipment was not provided. The use of plate guard is for resident having a hard time scooping food. Plate guard is use for easier scooping of food to prevent spillage and promote independence with feeding. V11 stated R135 was recommended with adaptive eating utensil due to her diagnosis of Huntington's disease, she has involuntary movements. R96's POS (physician order sheet) showed active order not limited to general diet, mechanical soft texture. MDS (minimum data set) dated 7/5/2024 showed R96's cognition was severely impaired. He needed partial / moderate assistance with eating. R96's meal ticket showed adaptive equipment: Plate guards. R135's POS (physician order sheet) showed active order not limited to general diet, mechanical soft texture. Divider plate, adaptive utensils / spoon. Care plan dated 6/8/23 documented in part: R135 have an ADL (activities of daily living) self-care performance deficit and impaired mobility. Eating: require partial weight assistance to eat using a weighted utensils for good holding and grip and divider plate to keep the food from spilling. R135's meal ticket showed divider plate to use + adaptive utensils (silver wares with rubber handles). MDS dated [DATE] showed R135's cognition was moderately impaired. She needed Supervision / touching assistance with eating. Facility's policy for restorative nursing program dated 8/19/24 documented in part: Evaluation as to the need of adaptive equipment / enabling devices to help accommodate the resident's needs, promote optimal functioning and self-sufficiency in ADL's.

Based on observation, interview and record review, the facility failed to implement fall precaution interventions for one (R2) resident identified as a fall risk out of three residents reviewed for fall precautions. Findings include: On 03/23/2024 at 9:02AM, surveyor observes a yellow star on R2's door next to R2's name. R2 observed lying in R2s' bed resting inside of R2s' room in a supine position with head of bed elevated at 45 degrees. R2s' floor mat was observed located in between two closet cabinets leaning against them in R2's room. R2's bed also observed to not be in the lowest position. On 03/23/2024 at 9:08AM, V5 (Agency Certified Nursing Assistant/CNA) states she works for an agency and this is the first time she has ever worked at the facility. V5 states she is the CNA responsible for caring for R2. V5 states she is aware that the yellow stars next to resident names indicate the resident is a fall risk. V5 states she was made aware by V4 (LPN) that V5 (Agency CNA) should watch those residents closely. V5 states she is not familiar with all the resident's fall precaution interventions. V5 states she is aware that she has only one major fall precaution resident to watch closely (identified as R4). V5 states R4 is the only resident she implemented fall precautions for. On 03/23/2024 at 9:15AM, V4 (Licensed Practical Nurse/LPN) located inside of R2's room and observes R2s' floor mat is not in place next to R2's bed. V4 also observes R2's bed was not in the lowest position. Surveyor observes V4 attempting to lower R2's bed and V4 states R2's bed remote is not working and R2's bed cannot be lowered. V4 states she has to call maintenance to fix R2's bed remote. V4 states R2 is a fall risk and R2's floor mat should have been on the floor next to R2's bed. V4 also states R2's bed should always be kept in the lowest position. V4 states if these fall precaution interventions are not implemented, then R2 can fall and hurt herself. On 03/23/2024 at 1:15PM, V8 (Fall Coordinator/RN) states she is the fall coordinator and has been working at the facility since November 2022. V8 states when a resident is admitted , they are assessed for their risk for falls by completing a fall risk assessment. V8 states the facility checks to make sure the residents are assessed for proper fall risk interventions and those interventions are then implemented. V8 states fall risk interventions are documented in the resident care plans. V8 states the yellow stars on the resident's doors are fall risk identifiers. V8 states in an effort to ensure staff is made aware of resident's fall precaution interventions, there is a stand up and stand down meeting held everyday, especially on the 4th floor. V8 states there is a green binder kept at every nurses' station that serves the purpose of a Fall communication tool for the nurses and CNAs. V8 states the green binders lists the residents who are on fall precautions, their acuity level, and the assistance they require. V8 states she is familiar with R2 and R2 should have floor mats and R2's bed in the lowest position as fall precaution interventions. V8 states R2 has never fallen at the facility but R2 has a history of seizures and is at risk for falls. On 03/23/2024 at 1:37PM, V8 returns with the green binder assigned to the 4th floor of the facility. V8 hands surveyor a document titled Weekly Fall Prevention Report 4th Floor. V8 states she prints new report sheets and puts them in the green binders every week on Fridays. Facility's 4th floor weekly fall prevention report documents R2's fall interventions requires R2 to have floor mats and R2's bed to be in the lowest position. R2's care plan dated 01/31/2024 documents a fall precaution intervention for R2's bed to be in the lowest position. R2's care plan does not document an intervention for floor mats. R2's fall risk assessment dated [DATE] documents R2 has a fall risk score of 9/10, indicating R2 is at high risk for falls. Facility policy dated 07/17/2023 titled Fall Occurrence documents in part, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Procedure- 2. Those identified as high risk for falls will be provided fall interventions. 8. The Fall Coordinator will add the interventions in the resident's care plan.

Based on interviews and record reviews the facility failed to maintain a resident's (R2) rights to privacy and confidentiality of personal and medical information for 1 of 3 residents reviewed for residents' rights. Findings include: On 02/16/2024 at 3:00 PM, V8 (R1's Power of Attorney for Healthcare) stated during R1's discharge, V9 put a bunch of medications in a bag and gave it to V8 without individually going through each medication blister pack. V8 did not realize R2's medications were also in the bag until a few days later. V8 received blister packs of R2's Escitalopram Oxalate 5 MG (milligram) and Levothyroxine 50 MCG (microgram). V8 stated the blister packs contain R2's name, doctor, medication name, dosage, and why R2 is on the medication - depression and hypothyroidism. V8 provided a picture of R2's medication label for Levothyroxine 50 MCG and Escitalopram 5 MG. Levothyroxine label documents in part prescription number, date of 11/22/2023, R2's previous room number, R2's name, medication name, dosage, frequency, and indication-hypothyroidism. Label also documents in part the pharmacy name and V10's (R2's Primary Physician's) name. The Escitalopram label documents in the prescription number, date of 12/02/2023, R2's current room number, R2's name, medication name, dosage, frequency, and indication-depression. Label also documents in part the pharmacy name and V10's (R2's Primary Physician's) name. On 02/18/2024 at 1:25 PM, V1 stated facility uses the pharmacy that was in the photo. R2's face sheet and physician orders document in part a medical diagnosis of hypothyroidism. R2's physician order sheets and medication administration records document in part an order for Escitalopram Oxalate Tablet 5 MG (milligram) Give 1 tablet by mouth one time a day for Depression and Levothyroxine Sodium Oral Tablet 50 MCG (microgram) Give 1 tablet by mouth in the morning for hypothyroidism. On 02/18/2024 at 8:36 AM, V4 (Nurse) stated the facility's medication blister packs for the residents contain the resident's name, room number, primary physician, medication name, dosage, frequency, and resident's diagnoses or indication as to why the resident is taking the medication. On 02/18/2024 at 10:58 AM, V7 (Memory Care Director) stated R1 and R2 were roommates. V7 stated there was no relation to the two. V7 stated R1's family or representatives should not have access to R2's personal or medical information. V7 stated only the people listed on the resident's face sheet should have access to the resident's personal information. Additionally, the resident or guardian will need to sign a release form to grant access for someone to receive a resident's personal and medical information. V7 stated there were no medical record release forms for R1 or R1's representatives to have access to R2's records. Reviewed R2's face sheet and it does not list R1 or V8 under 'Contacts.' Facility's Privacy and Dignity policy last revised 07/28/2023 documents in part: It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times. Residents health information will not be shared to anyone who is not involved in resident's care and to anyone whom the alert and oriented resident does not wish to share his/her information with.

Based on interview and record review, the facility failed to ensure that resident belongings were returned after discharge for one (R2) of three residents reviewed for misappropriation of resident property. Findings include: R2's face sheet documents that R2 was discharged from the facility to a local psychiatric hospital on 08/11/2023. R2 is no longer at the facility. On 09/30/2023 at 12:05 PM, V8 (R2's family member) stated that approximately at the end of August 2023, she informed V3 (Social Services Director) and V4 (Social Services Coordinator) of R2's missing money totaling $49 dollars and R2's missing belongings. V8 stated that she had been in contact with V3 and V3 told her that R2 did not have any belongings at the facility. V8 stated she had been in contact with V4 and V4 stated that he would follow up with V8 regarding R2's missing belongings. V8 stated it had been weeks since she heard anything so she contacted V1 (Assistant Administrator) and told V1 about R2's missing belongings. V8 stated that R2 informed her that R2 just received his $49 dollars last night after waiting over a month to receive it. V8 stated that she was informed by R2 that someone from the facility dropped R2's money off at R2's current nursing home residence but R2 is unaware of who dropped off his money to him. V8 stated that R2 signed his name that he received his money. V8 stated R2 is still missing items that was ordered online by V8 and other family members. V8 stated R2 is missing a box with multiple bags of snacking chips, 4 pairs of reading glasses, and 2 large print books. V8 stated another family member ordered the box of chips for R2 and V8 ordered the 2 large print books recently. V8 states that an email confirmation from an online store shows that R2's package was delivered to the facility. V8 stated she spoke with V1 (Assistant Administrator) this week on Monday and V1 informed V8 that V8 has to purchase new items and show proof of those receipts before the facility will reimburse V8. V8 stated she does not agree with that decision. V8 states that she is familiar with how the long-term care process works. V8 states when a resident is sent out to the hospital, the facility is supposed to keep the resident's items in a storage room until the resident returns from the hospital. On 09/30/2023 at 1:30PM, V1 (Assistant Administrator) stated when a resident leaves the facility, their belongings are put into storage. V1 states she spoke with V8 (R2's family member) and told V8 that R2's money would be dropped off to R2. V1 stated R2's money is the only thing that the facility had and V3 (Social Services Director) was in possession of R2's money. V1 stated she searched the storage room and could not find R2's belongings. V1 stated that other staff members also searched the facility and could not find R2's belongings. V1 stated V9 (Environmental Services Director) is usually the person responsible for placing the resident items in storage when a resident is admitted to the hospital. On 09/30/2023 at 3:00PM, V9 (Environmental Services Director) stated she has been working at the facility for [AGE] years. V9 stated the protocol when a resident is discharged to the hospital is the staff will first disinfect the room. If the admission department informs us that a resident will not be returning to the facility, then we are instructed to put the resident belongings in storage. I was made aware that R2 was not coming back to the facility by V10 (Admissions Director). V10 informed me of this information about 5-7 days after R2 was hospitalized . An inventory of R2's belongings was not made when R2 went out to the hospital. Once I was made aware, I went into R2's room with V13 (Laundry Aide) about 5-7 days after R2 went out to the hospital. There were other housekeeping staff assigned to clean R2's room when R2 was in the hospital. I asked them have they seen any of R2's belongings and they have not seen them either. V13 and I both went into R2's room together. V13 stated to me that she searched the laundry room for R2's belongings and did not find any belongings for R2. Myself and V13 searched R2's room for any other belongings, we checked everything inside of R2's room and even the drawers but we did not see any of R2's belongings. There was nothing. I do remember seeing R2 with some glasses, they were big glasses. When we started looking for R2's belongings. I checked the storage room and there was nothing. If there is nothing found in the resident's room, then there is nothing to be filled out. If there are items found in a resident's room, then we fill out an inventory form that documents the resident's name, the date, and the items found. Myself, V13, and V1 all searched the storage room in hopes of finding R2's belongings. The storage room is located on the first floor of the facility. The housekeeping staff has access to and shares one key to the storage room. The CNAs are responsible for obtaining an inventory list of all the resident's belongings upon admission and discharge. We also tell residents and their family to let us know if they bring in or purchase new items for the resident so that we can update the resident's inventory list. On 09/30/203 at 1:55 PM, V3 (Social Services Director) stated I gave R2 an envelope to put his money in before R2 was going out to the hospital so that R2 could take his money with him. R2 left the envelop at the facility when he went out to the hospital. I am not aware of any other missing belongings that R2 had, I only know about the money. On 09/30/203 at 2:29PM, V2 (Director of Nursing/DON) presented R2's resident belongings log dated 04/13/2023. R2's resident belonging log documents 1 pair of glasses and $8 in cash. On 10/01/2023 at 9:21 AM V10 (Admissions Director) stated I was made aware of R2's missing items by the nursing and housekeeping staff. I was informed that R2 had some money, books, and glasses, and some clothes. I observed R2's inventory list when R2 was discharged from the facility. I saw the items on the list that R2's family was inquiring about. I saw this inventory list probably less than a week after R2 was sent to the hospital. To my knowledge, the housekeeping staff packed up all of R2's belongings and it should be in the storage room. I did not see R2's items and belongings but I did see the actual inventory list. This list is kept in the resident's chart. I have seen this inventory list in R2's medical chart, it is in there. When a resident is not returning back to the facility, I always tell the housekeeping staff to search the resident's room. I instruct the housekeeping staff to pack the resident's belongings because I know that the family will need them. I was informed that V1 (Assistant Administrator) addressed the concerns with R2's missing money and R2's money was returned and dropped off to R2 by V3 (Social Services Director). On 10/01/2023 at approximately 2:15 PM, Surveyor requested an inventory list of R2's belongings upon discharge from V2 (Director of Nursing). R2's discharge inventory list was not provided to surveyor. There was no documentation presented during this survey to show that R2's belongings were inventoried after R2's discharge from the facility. On 10/01/2023 at 10:57 AM, V4 (Social Services Coordinator) stated I've been working here for four months. I spoke with V8 (R2's family member) when she called and V8 told me about R2's missing items. V8 asked about R2's money which was $49 dollars and other items missing but I can only remember V8 mentioning some pairs of glasses that were missing. I told V8 that I would inform V1 (Assistant Administrator). On 10/01/2023 at 2:10 PM, V1 (Assistant Administrator) presents surveyor with a written concern/grievance form dated 09/20/2023 documenting a concern made by R2's family about R2's missing items. V1 stated she was currently in the process of awaiting a receipt from V8 (R2's family member) to attach to the form so she had the form in her possession. V1 stated she forgot to give the concern/grievance form to surveyor when the concern/grievance logs were requested and reviewed by surveyor on 09/30/2023. On 10/02/2023 at 2:19 PM, V16 (Ombudsman) stated she was informed of R2's missing belongings by V8 (R2's family member). V16 stated that V8 informed her that R2 was missing money, books, eyeglasses, and clothes. V16 stated she reached out to the facility to address V8's concerns but has not heard back from anyone at the facility. Facility policy dated 11/28/2017, titled Abuse and Neglect documents in part, It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. 6. Financial/Misappropriation of property: financial abuse includes, but not limited to deliberate misplacement, misappropriation, exploitation or otherwise taking advantage of a resident's money or property temporarily or permanently. Must be reported includes theft of personal property, including but not limited to jewelry, computer, phone, and other valuable items such as eyeglasses and hearing aides. Facility policy dated 07/28/2023, titled Transfers and Discharges, documents in part, After transfer or discharge if it becomes clear the resident will not return to the facility, facility staff will pack the former resident's belongings within 24 hours . the former resident's belongings will be safely stored by the facility for no less than 30 days or no more than 60 days. Facility policy dated 07/28/2023, titled Personal Belongings List documents in part, It is the policy of the facility to protect the resident's belongings from being misplaced and from theft. In order to prevent this, the facility will ensure that the resident's belongings are tracked accurately. 5. All missing items alleged as missing by the resident or family member will be investigated thoroughly.

Based on interview and record review, the facility failed to report and investigate misappropriation of property for one (R2) of three residents reviewed for misappropriation of resident property. Findings include: On 09/30/203 at 12:05 PM, V8 (R2's family member) stated that approximately at the end of August 2023, she informed V3 (Social Services Director) and V4 (Social Services Coordinator) of R2's missing money totaling $49 dollars and R2's missing belongings. V8 stated that she had been in contact with V3 and V3 told her that R2 did not have any belongings at the facility. V8 stated she had been in contact with V4 and V4 stated that he would follow up with V8 regarding R2's missing belongings. V8 stated it had been weeks since she heard anything so she contacted V1 (Assistant Administrator) and told V1 about R2's missing belongings. On 09/30/2023 at 3:35 PM, V1 (Assistant Administrator) stated she did not report allegations of theft to the state agency and was currently in the process of reporting to the state agency. V1 states she did not report this because the term theft was never mentioned to her by R2's family whom V1 has been speaking with. V1 stated she was made aware by V8 (R2's family member) of R2's missing money and belongings on 09/20/2023. V1 stated that based on surveyor's questions and inquiries of theft, she would file a report with the state agency, surveyor does not consult V1 on any actions to take. Facility reported incident reviewed for the past 3 months and does not document a report of theft or misappropriation of property for R2. Facility policy dated 11/28/2017, titled Abuse and Neglect documents in part, It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. V. Investigation: Investigate all allegations of abuse, neglect, exploitation, and misappropriation of property. Thorough documentation of the investigation. VII. All allegations and/or suspicions of abuse must be reported to the administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee.

Based on interview and record review, the facility failed to provide their bed hold policy, upon discharge to hospital, for one (R2) of three resident reviewed. Findings include: R2's medical record (Face Sheet, MDS/Minimum Data Set, dated dated dated [DATE] documents R2 is a [AGE] year-old male who is cognitively intact with a BIMS/ Brief Interview for Mental Status score of 14/15. R2 has diagnoses not limited to: metabolic encephalopathy, dysphagia, schizoaffective disorders, major depressive disorder, atrial fibrillation, chronic kidney disease, and post-traumatic stress disorder. On 10/01/2023 at 9:21 AM V10 (Admission Director) stated I sent out a bed hold notification to management and it's a template that I always follow when I send out the bed hold notifications. I send this template out via email every time a resident goes out to the hospital. I am not familiar with the bed hold policy but I do not send anything directly to the resident or their families, I only send it internally to V11 (Hospital Liaison) and the managers. The facility is required to hold a residents' bed for 10 days during hospitalization in order to accommodate the resident. On 10/01/2023 at 1:55 PM, V1 (Assistant Administrator) states that a bed hold notification was not provided to R2 or R2's family. There is no documentation to show that R2 or R2's family was made aware of the facility's bed hold policy. Facility's policy dated 07/27/2023, titled Bed Hold and Readmission documents in part 1. The facility must inform the resident or family member being transferred of the duration of bed hold in writing. Facility policy dated 07/28/2023, titled Transfers and Discharges, documents in part, The resident will then be given a bed reserve policy upon discharge to the hospital.

Based on observations, interviews, and record reviews, the facility failed to ensure that the low air loss mattress is set on the appropriate setting for 4 residents (R30, R32, R94, and R136) reviewed for pressure ulcer prevention in the total sample of 57 residents. Findings include: 1. On 08/28/23 10:34 AM, R32 was lying on a low air loss mattress with a setting below 80lbs. This observation was pointed out to V14 (Certified Nursing Assistant). V14 stated setting is below 80 and normal pressure. On 08/28/23 10:53 AM, V11 (Wound Care Coordinator) stated I (V11) am checking the setting of the low air loss mattresses. I (V11) started at the 4th floor going down to 2nd floor. V11 checked R32's weight on the sheet of paper V11 was holding on the request of the surveyor and stated she (R32) weighs 157lbs. V11 then checked R32's setting of low air loss mattress and stated it's below 80lbs. The support surface is much softer; the low air loss mattress is not used to the full extent. On 08/30/2023 at 12:45 pm, V 11 stated if the resident weighs 157 pounds, the setting of the low air loss mattress should not be below 80lbs. It is too low. The low air loss mattress does not provide enough support to the resident and may contribute to impaired skin integrity, it may cause a skin breakdown. R32's (Active Order As Of: 08/29/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypertension, senile degeneration of brain, and encounter for palliative care. R32's (03/08/2021) Braden Scale for Predicting Pressure Sore Risk documented that R32 scored 16. Indicating R32 was at risk for developing pressure sore. R32's (08/29/2023) Preventive Interventions Worksheet documented that R32's Braden score was 15. At risk for developing pressure sore. R32's (undated) Weights and Vitals Exception documented that on 08/15/2023, R32 weighed 157.0lbs. R32's (08/15/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 'no entry'. C0700. Short-term memory OK. 1. Memory problem. C0800. Long-term memory OK. 1. Memory problem. Section M. Skin Conditions. M0150. Risk of Pressure Ulcers/Injuries. Yes. M1200. Skin and Ulcer/ Injury Treatments. B. Pressure reducing device for bed. The (undated) 8 Alternating Pressure & Low Air Loss Mattress System with Foam Base User Manual documented, in part Intended Use. The pump and mattress are intended to help reduce the incidence of pressure ulcers while optimizing patient comfort. Pressure Adjust Knob adjustable by patient's weight. Turn the pressure adjust knob to set a comfortable pressure level by using the weight scale as a guide. Operating Instruction. 9. Turn the Pressure Adjust Knob to set a comfortable pressure level using the weight scale as a guide. 41611 2. R30 has a diagnosis of but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Benign Neoplasm of Cerebral Meninges, Type 2 Diabetes Mellitus, Chronic Respiratory Failure, Chronic Embolism and Thrombosis of unspecified Vein and Chronic Obstructive Pulmonary Disease with Acute Exacerbation. R30's Brief Interview for Mental Status is 07 that indicates Moderately impaired. On 8/28/2023 at 10:55 am, surveyor observed R30's low air loss mattress set at about 120lbs. On 8/29/2023 at 2:31 pm, surveyor reviewed R30's weights and vitals in PCC (Point Click Care Software) and R30's weight is 127.6lbs as of 8/04/2023. On 8/30/2023 at about 12:30 pm, R30's low air loss mattress was set at about 120lbs. R30's Order Listing Report with active orders as of 8/30/2023 documents, in part, LAL (Low Air Loss) pressure alternating mattress for offloading. R30's care plan focus for actual impairment to skin integrity dated 1/29/2023 documents, in part, alternating low air loss mattress in use. 3. R94 has a diagnosis of but not limited to Alzheimer's Disease, Major Depressive Disorder, Malignant Neoplasm of Colon, Type 2 Diabetes, and Protein-Calorie Malnutrition. R94's Brief Interview for Mental Status is 99 that indicates the individual chooses not to participate, or 4 or more items were coded 0 because the individual chose not to answer or gave a nonsensical response. On 8/28/2023 at 11:31 am, surveyor observed R94's low air loss mattress set at about 120lbs. On 8/29/2023 at 2:31 pm, surveyor reviewed R94's weights and vitals in PCC (Point Click Care Software) and R94's weight is 88.2lbs as of 8/4/2023. On 8/30/2023 at about 12:30 pm, R94's low air loss mattress was set at about 238lbs. R94's care plan focus for potential impairment to skin integrity date 3/30/2023 documents, in part, LAL (Low Air Loss) mattress for treatment and prevention of pressure injury. R94's Order Listing Report with active orders as of 8/30/2023 documents, in part, LAL (Low Air Loss) Mattress for treatment and prevention of pressure injury. On 8/30/2023 at 12:39 pm, V11 (Wound Care Coordinator) stated the wound care staff initially do the settings for the low air loss mattresses and stated that the low air loss mattress should be set for comfort and the weight of the resident. Stated if the setting is high, based on the resident's weight, you are putting more pressure on the wound and if the setting is too low it would not provide enough support for the resident. 32338 4. On 8/28/23 at 10:59 am, R136 was observed on Low Air Loss Mattress (LALM) with setting at 270 pounds. Again at 11:45 am, the LALM was still at the same setting of 270 pounds. R136's weight records show that R136 weighs only 90.8 pounds. R136's care plan dated 5/10/23 states that R136 is a [AGE] year-old resident with potential for impairment to skin integrity related to multiple diagnoses. R136's Physician Order Sheet dated 2/14/23 states Low Air Loss Mattress for prevention and treatment of pressure injury. R136's pressure ulcer risk assessment dated [DATE] states that R136 had a score of 12 (high risk for pressure ulcer). Latest assessment dated [DATE] had a score of 13 (moderate risk). On 8/30/23 at 11:55 am, V11 (Wound Care Coordinator) was asked about the importance of correct weight settings for LALM in pressure ulcer prevention. V11 stated that the mattress should be at the correct weight settings.

Based on observations, interviews, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change, failed to document dispensing of controlled medication, and failed to follow pharmacy instruction to refrigerate medications. These failures affected 4 residents (R27, R110, R140, and R141) reviewed for pharmacy services and records and have the potential to affect all 44 residents on 2nd floor Team 2 and 3rd floor Team 3. Findings include: The (08/31/2023) email correspondence with V1 (Administrator) documented that 2nd floor Team 2 include residents in rooms 214, 215-2, 217-229; and 3rd floor Team 3 include residents in rooms 303, 305, 306-312. The (08/28/2023) Daily Census documented that there were 27 residents in 2nd floor Team 2 and 17 residents in 3rd floor Team 3. On 08/29/2023 at 12:01 pm, on 3rd floor, during the medication storage and labeling task of the medication cart labeled as Team 3, surveyor along with V19 (Registered Nurse) observed that R141's Morphine Sul (sulfate) Tab 30 mg ER (extended release) Individual Controlled Substance Record indicated that there were 12 tablets left in the controlled cart. V19 (Registered Nurse) stated there were 11 tablets left in R141's dispensing card. I (V19) have not signed out yet the one I (V19) gave this morning. I (V19) am supposed to sign after I (V19) gave the medication. On 08/29/2023 at 12:33 pm, on 2nd floor, during the medication storage and labeling task of Team 2 medication cart along with V21 (Registered Nurse), surveyor observed R27's, R110's, and R140's Dronabinol's dispensing cards kept in the controlled medication box, and not in the refrigerator. R27's, R110's, and R140's Dronabinol's Controlled Drug Administration Record Tablet sheets had instruction to Refrigerate. V21 stated I (V21) kept these in the med cart this morning when (V21) counted the controlled medications with the outgoing nurse. The (08/2023) Controlled Substance Check Form on 2nd Floor Team 2 has missing signatures on day 3, 11-7 shift, Nurse On; day 4, 7-3 shift, Nurse Off and 11-7 shift, Nurse On; day 5, 7-3 shift, Nurse OFF, and 11-7 shift, Nurse On; day 6 7-3 shift, Nurse OFF; day 11, 11-7 shift, Nurse On; day 21, 7-3 shift, Nurse OFF; day 26 11-7 shift, Nurse On; day 27, 7-3 shift, Nurse OFF. The (08/2023) Controlled Substance Check Form in 3rd Floor has missing signatures on day 10, 11-7 shift, Nurse On; day 25, 11-7 shift, Nurse On; day 26, 11-7 shift, Nurse OFF. On 08/30/2023 at 12:00 pm, V2 (Director of Nursing) stated there should be a count of the controlled medications during the shift change between the incoming and outgoing nurses. The two nurses should sign after they counted the medications. These are controlled medication, there is a proper counting of controlled medications. It is part of regulation, to get accurate count of the controlled medication. Staff are expected to sign immediately after counting. On 08/30/2023 at 12:03 pm, V2 stated that immediately after they have dispensed the controlled medication, the staff is expected to document that the controlled medication is dispensed from the controlled by signing it off. For proper accounting of controlled medications. On 08/30/2023 at 12:12 pm, V2 stated if the pharmacy recommendation is to refrigerate the medication, then the medication should be refrigerated. To maintain the potency of the medication and to keep the consistency of the medication. Dronabinol gel could get soft. The expectation is to follow the pharmacy recommendation. R27's (Active Order As Of: 08/29/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) multiple sclerosis. Order Summary. Dronabinol Capsule 5mg give 5mg by mouth two times a day. R27's (Date Received: 08/15/23) Controlled Drug Administration Record Tablet documented, in part Dronabinol 5mg cap. Refrigerate. R110's (Active Order As Of: 08/29/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) heart failure, hypertension, and protein calorie malnutrition. Order summary. Dronabinol Capsule 2.5mg give 1 capsule by mouth one time a day. R110's (date received: 8/3/23) Controlled Drug Administration Record Tablet documented, in part Dronabinol 2.5mg cap. Refrigerate. R140's (Active Order As Of: 08/29/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) wedge compression fracture, hypertension, and spinal stenosis. Order Summary. Dronabinol Oral capsule 2.5mg give 2 capsule(s) by mouth one time a day. R140's (Date Received: 8/22/23) Controlled Drug Administration Record Tablet documented, in part Dronabinol 2.5mg cap. Refrigerate. R141's (Active Order As Of: 08/29/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) malignant neoplasm of lymph node, palliative care, and hypertension. Order Summary. Morphine Sulfate tablet 15mg. Give 2 tablets every 12 hours for severe pain. R141's (Schedule date: 08/29/2023 - 08/29/2023) Medication Admin (Administration) Audit Report documented, in part Order Summary. Morphine Sulfate Tablet 15MG Give 2 tablets by mouth every 12 hours. Schedule date. 08/29/2023 09:00 (9am). Administration Time. 08/29/2023 09:18 (9:18am). Doc'd (documented) by V19 (RN). R141's (Date Received: 8/10/23) Individual Controlled Substance Record for Morphine Sul (Sulfate) Tab 30MG ER documented that the last entry was on 'Date' 8/28, 'Time' 9pm, 'Amount Remaining' 12. The (7/2023) Controlled Medications Count policy and procedure documented, in part Policy Statement. It is the policy of the facility to maintain an accurate count of Scheduled II controlled medications. Procedure. 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign of the accompanying controlled medication sheet indicating the medication is taken. The (08/2020) Storage of Controlled Substance policy and procedure documented, in part Policy. Medications classified by the Drug Enforcement Administration (DEA) as controlled substance are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures. 3. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. 5. Unless otherwise indicated in a facility policy and/or as required by state regulations, the following will be performed: a. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented. 7. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and documented on a control count sheet (or similar form) or in accordance with facility policy and state regulation.

Based on observations, interviews and record reviews, the facility failed to ensure medication vials are contained in original packaging for 1 resident (R142), failed to discard expired flu vaccine, failed to check the temperature of vaccine refrigerator at a minimum of two times daily, and failed to ensure the refrigerator was within the required temperature. These failures have the potential to affect all the residents on 3rd floor. Findings include: On [DATE] at 11:48 am, on 3rd floor, during the medication storage and labeling task of the medication cart labeled as Team 3 along with V19 (Registered Nurse), surveyor observed 4 cyclosporin eye drop vials in the first drawer without labels and not contained in original packaging. This was pointed out to V19. V19 stated those are for (R142); they are not in original packaging. V19 opened the bottom drawer of the medication cart and showed this surveyor the original packaging of the cyclosporin eye drop vials. The original packaging had R142's identifier and inside the box were foil containers where the cyclosporin vials were stored. V19 stated these (referring to the cyclosporin vials not in original packaging) should be in original packaging to prevent contamination and to prevent giving to another resident because these are not labeled. On [DATE] at 12:13 pm, on 3rd floor during the medication storage and labeling task with V20 (Registered Nurse) of the 3rd floor medication storage room, surveyor observed that the medication refrigerator had 8 vials of pneumococcal vaccine polyvalent 23, 6 prefilled syringe pneumococcal 13-valent conjugate vaccines, and 1 prefilled syringe influenza Vaccine with expiration date of 2023-Apr-30. On [DATE] at 12:20 pm, the thermometer inside the medication refrigerator registered the temperature at 30F. V20 stated the temperature is not within the range. The purpose of keeping the medication refrigerator within the temperature range is to make sure the medications are still viable and effective. On [DATE] at 12:22 pm, surveyor inquired how often the facility checked the medication refrigerator temperature. V20 stated we check the temperature once a day by the night shift nurse. On [DATE] at 12:05 pm, V2 (Director of Nursing) stated the expectation is for the nurse to check the temperature of the refrigerator twice daily, if there are vaccines. The importance is to make sure the temperature is maintained during storage. To maintain the potency and effectiveness of the vaccines. It is not expected to store expired vaccines because it may be given to the resident. On [DATE] at 12:08 pm, V2 stated refrigerator temperature should be between 36F to 46F per manufacturing guideline. Thirty degrees Fahrenheit is too cold. It can affect the potency of the vaccines and medications. On [DATE] at 12:17 pm, V2 stated medications should be kept in original packaging because the identifier of the resident and the instruction on how to give the medication is in the original packaging. R142's (Active Order As Of: [DATE]) Order Summary Report documented, in part Diagnoses: (include but not limited to) primary hypertension, osteoarthritis, and shortness of breath. Order Summary. Cyclosporine emulsion 0.05% instill 1 drop in both eyes every morning and at bedtime. The (,d+[DATE]) Daily Temperature Log in 3rd floor Nurses Station indicated the refrigerator temperature was checked once nightly. Refrigerator Temperature Range low- 34 degrees (F). High - 42 degrees (F). The (undated) Temperature Monitoring Best Practices for Refrigerated Vaccines-Fahrenheit (F) documented, in part 1. Store vaccines at ideal temperature: 40F. Within range 36F to 46F. 2. Record daily temperatures. 3steps daily: 1. Note: if your device does not display min (minimum)/max (maximum) temperatures, then check and record current temperature a minimum of 2 times (at start and end of workday). The (,d+[DATE]) Storage of Medications policy and procedure documented, in part Policy. Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. I. Procedures. 1. The provider pharmacy dispenses medications in containers that meet regulatory requirement, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. 3. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. 8. Outdated medications are immediately removed from inventory, disposed of according to procedures for medication disposal. II. Temperature. 1. All medications are maintained within the temperature ranges noticed in the USP and by the Centers for Disease Control (CDC). c. Refrigerated: 36F to 46F with a thermometer to allow temperature monitoring. 2. Medications and biologicals are stored at their appropriate temperature and humidity according to the USP guideline for temperature ranges. 3. Medications requiring refrigeration are kept in a refrigerator at temperature between 36F and 46F. 7. The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC Guidelines. III. Expiration Dating (Beyond-use dating). 8. All expired medication will be removed from the active supply and destroyed in the facility.

Based upon observation, interview and record review the facility failed to provide supervision to (R2, R4) and failed to implement appropriate fall prevention interventions for three of four residents (R2, R3, R4) reviewed for falls. These failures resulted in R2 sustaining (1/5/23) fall with facial injury and (acute) right tibia & fibula fractures. Findings include: R2's diagnoses include Alzheimer's disease, repeated falls. (8/17/22) fracture of shaft of left fibula and (9/8/22) fracture of shaft of right tibia. R2 was transferred to the hospital (1/11/23) and did not return to the facility. R2's (11/23/22) BIMS (Brief Interview Mental Status) determined a score of 5 (severe impairment). R2's (11/23/22) functional assessment affirms (2 person) physical assist is required for bed mobility and transfer. R2's (11/23/22) fall risk evaluation states right lower extremity is weak with tendency to go externally with non-mixed minimal foot drop. (Left) lower extremity is with limited movement related to fracture of the fibula with tendency to internally rotate. Extensive assist of 2 on mobility. (High risk for fall). R2's initial FRI (Facility Reported Incident) includes type of incident: unwitnessed fall (with injury). Location of incident: Bedroom. On 1/5/23 at 6:45 pm, resident was observed lying on the floor. Resident was observed with a bump on the left side of the head. Resident was sent to hospital for further evaluation. On 1/27/23 at 8:32 am, surveyor inquired about R2's (1/5/23) fall V3 (Family) stated She (R2) was [AGE] years old. I don't know how she (R2) would fall because she's bed bound. They (Facility) said that she (R2) fell face down on the floor and couldn't give me a direct answer on how it happened. Surveyor inquired about R2's fall prevention interventions prior to (1/5/23) fall V3 responded they (Facility) don't have any mats on the floor, they didn't have anything. R2's (8/17/22) care plan states resident is at risk for falls related to medication use, poor safety awareness, unsteady gait and disease process. Side rails to prevent rolling out of bed. Use assistive device during ambulation to prevent falls. Keep call light within reach when in bedroom or bathroom. [Floor mats were excluded prior to 1/5/23 fall]. On 1/28/23 at 3:08 pm, surveyor inquired about R2's cognitive and functional status. V2 (Director of Nursing) stated, She's alert and oriented times one and I believe she has dementia as well. She's totally dependent (2 person assist) as far as bed mobility and self-performance. Surveyor inquired if R2 was ambulatory. V2 responded, She's bed bound. Surveyor inquired about R2's fall prevention interventions prior to (1/5/23) fall. V2 replied, Resident was categorized as a high risk for falls so the call light is within reach, she was in therapy for mobility and strength, bed in the lowest position and after the fall the intervention was the floor mats. On 1/29/23 at 11:40 am, surveyor inquired about R2's (1/5/23) fall V10 (Agency Registered Nurse) stated I was in the middle of an admission. She (R2) was found on the floor they (staff) came and told me. When I (V10) got there, she (R2) was face down in the prone position (beside the bed). Surveyor inquired if R2 was ambulatory. V10 responded, She's bed bound, she can't walk. Surveyor inquired if fall preventive interventions were in place prior to R2 falling. V10 replied, I think there was rails raised on the bed and affirmed that she (V10) was unsure. R2's (1/5/23) hospital progress notes state patient is [AGE] years old admit after a fall with multiple injury to face and right lower leg fracture. R2's (1/6/23) right ankle x-ray includes comminuted fracture through the distal tibia and fibula. R2's (1/6/23) history & physical states patient fell at nursing home and had acute pain. Workup shows (acute) tibia/fibula fracture on the right. On 1/29/23 at 2:26 pm, surveyor inquired about potential harm to a resident that sustains an unwitnessed fall V13 (Medical Director) stated It could be anything. Surveyor responded what type of injuries could be sustained? V13 replied, I'm sorry I cannot exactly recall any type of injury. Surveyor inquired about potential harm to a resident post fall (in general) like skin impairment, fracture, or subdural hematoma. V13 stated, Patients could have injuries after falls, it could be something it could be nothing. It could be something small it could be something large it could be anything. Surveyor inquired what anything entails. V13 responded, We have a whole set of procedures I couldn't get into the details right now because every case is individualized and refrained from answering the questions directly. __ R4's diagnoses include dementia with mood disorder, anxiety disorder, cognitive communication deficit and difficulty in walking. R4's (11/21/22) BIMS determined a score of 4 (severe impairment). R4's (11/21/22) functional assessment affirms (2 person) physical assist is required for bed mobility and transfer. R4's (1/21/23) fall risk assessment determined a score of 15 (high risk). R4's (11/17/22) care plan states resident is at high risk for falls related to periods of anxiety. Provide me with activities to minimize the potential for falls while providing diversion and distraction while in the activity room specially in the morning while waiting for breakfast. Toilet me every 2 hours and as needed to prevent unassisted attempts to go to the toilet. R4's incident reports include (12/26/22) & (1/21/23) falls. On 1/28/23 at 12:56 pm, surveyor inquired about R4's fall prevention interventions. V9 (Licensed Practical Nurse) stated, We usually making sure when she's in the bed it's in the low position, the floor mat in place we also give her the call light within reach and all her personal belonging close to her for reach. Remind her that if she need anything to call, she can use the call light. Also, we do the frequent rounding to check on her. She cannot walk. We do have CNA's (Certified Nursing Assistants) who is usually watching them, we have some other patients too needing watched. Surveyor inquired about R4's (1/21/23) fall. V9 responded, The patient was in the dining room. Activity (staff) just called me and said she (R4) was on the floor. She (R4) was lying on her right side next to her (Brand name wheelchair). It was unwitnessed fall so I'm not really sure what happened to her or how she end up on the floor. Surveyor inquired if the dining room is supposed to be supervised when residents are placed there. V9 responded, Yes, we have like two (2) activity aides and one (1) CNA (Certified Nursing Assistant) in there. On 1/27/23 at 12:55 pm, R4 was observed (in the dining room) seated in a modified wheelchair (reclined position) with both legs dangling over the arm of the wheelchair and arms flailing about. R4 was also noted to be wearing a (soft collar) neck brace. V5 (Activity Aide) attempted to place pillows next to R4 to no avail because R4 was restless, removed the pillows and would not follow redirection. Surveyor inquired about R4. V5 stated, When she's done eating already, she wants to just keep on moving. She's the same language and dialect as me so I can communicate that you're gonna fall or that one. Surveyor inquired about R4's fall preventions interventions V5 replied We just watch her one on one with her pillows. Surveyor inquired why R4 was attempting to get out of the wheelchair. V5 stated, She's just only trying to move, she don't say anything to me. V5 made no attempt to provide a diversion, distraction and/or activity [as directed per care plan]. __ R3's diagnoses include dementia and morbid obesity. R3's (1/16/23) BIMS determined a score of 9 (Moderate Impairment) R3's (1/16/23) functional assessment affirms (2 person) physical assist is required for bed mobility and transfer. R3's (1/16/23) fall risk assessment determined a score of 13 (high risk). R3's (3/13/20) care plan states resident is at risk for falls related to incontinence, forgetfulness, and bilateral lower extremity weakness. Follow the facility fall protocol. The resident needs a safe environment with a working reachable call light and bed in low position. On 1/27/23 at 12:37 pm, surveyor observed R3 (from the hallway) lying in bed and the bed was in high position. On 1/27/23 at 12:42 pm, surveyor inquired about R3's fall prevention interventions. V4 (Registered Nurse) stated, We have the bed set in lowest position and the call light is within reach. She's alert and oriented. Surveyor inquired about the current height of R3's bed. V4 subsequently observed R3 and responded, The bed just need to lower it a little more because it's not in the lowest position. Surveyor entered the room and affirmed that the height of R3's bed was thigh level. The call light button was observed near R3's right elbow however R3's right hand was splinted. Surveyor inquired about R3's call light access, R3 struggled to access the call light button due to placement (near elbow), right hand splinted and left hand severely contracted. Surveyor inquired if R3 was able to activate the call light. R3 was unable to push the button with her fingers and/or thumb therefore activated the button by hitting herself with the device (on the forehead) multiple times before able to do so. Surveyor inquired about concerns with R3's handheld call light. V4 responded. She has to put it on her head, she needs like a push button. The fall occurrence policy (reviewed 5/17/22) states those identified as high risk for falls will be provided fall interventions. The call light policy (reviewed 7/27/22) states be sure call lights are placed within reach of residents who are able to use it at all times. If a call light is not functional, evaluate and provide another means in order for the resident to call for assistance.

Based on observation, interview and record review, 1. Facility failed to ensure that one resident (R1) with known diagnosis of seizures, psych disorders; use of anticoagulants and history of scissors puncturing him in the past is free of accident hazards such as grooming scissors, stainless steel blades and other hazards; 2. Facility failed to assess if R1 is appropriate to use grooming scissors independently; 3. Facility failed to provide assistance and supervision to a resident who requires assistance for personal hygiene and grooming. As a result of the facility's failures, on 9/18/2022, R1, was found with bleeding in the right lower abdominal area with a pair of scissors embedded in R1's abdominal wall. R1 was sent to the hospital where CT of the abdomen and pelvis under Impression documents in part: Scissors embedded in the subcutaneous tissue of the right lateral anterior abdominal wall. These failures affected one of three (R1) residents reviewed for hazards and accidents. On 10/12/22 at 10:15 AM, R1 had in his possession two sharp, pointed grooming scissors, and a box of 4 stainless steel blades used for shaving at his bedside. The Immediate Jeopardy started on 09/18/22 at 2:05 AM, when R1 was found bleeding in the right lower abdominal area with a pair of scissors embedded in R1's abdominal wall. The Immediacy was removed on 10/14/2022. V1 Administrator and V2 Director of Nursing/DON, were informed of the Immediate Jeopardy and the Immediate Jeopardy Template was presented on 10/13/2022 at 12:47 PM. The facility provided an initial removal plan on 10/13/2022 at 5:00 PM which was not accepted. The facility provided a revised removal plan on 10/17/2022 and the plan was accepted on 10/17/2022. Although the immediacy was removed, the deficiency remains at the second level of harm until the facility can determine the effectiveness of the implementation of the removal plan. Findings include: R1's medical record showed that R1 was admitted to the facility on [DATE]. Diagnosis includes but not limited to: [CONDITION(S)], [CONDITION(S)], Lumbago with Sciatica, [CONDITION(S)] and Collapse, [CONDITION(S)] and [CONDITION(S)] following unspecified [CONDITION(S)] Disease, [CONDITION(S)] with lower urinary tract symptoms, Opioid Dependence, [CONDITION(S)] Heart Disease of Native Coronary Artery without [CONDITION(S)] Pectoris, [CONDITION(S)], Type 2 Diabetes Mellitus with Diabetic [CONDITION(S)], Constipation, [CONDITION(S)], Other Generalized [CONDITION(S)] and Epileptic Syndromes, Major Depressive Disorder, Anxiety Disorder, Radiculopathy, Obesity, Post Traumatic Stress Disorder, Old [CONDITION(S)], Need for Assistance with personal care, Chronic Pain, Unspecified Convulsions, and Essential Hypertension. R1's Minimum Data Set (MDS) dated [DATE], Section C- Brief Interview for Mental Status Score is 14 indicating R1 is cognitively intact. Section G of the MDS affirms that R1 requires limited assistance for personal hygiene. CMS 3.0 RAI Manual dated October 2019 on page G-4 defines Personal Hygiene as how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers). R1's progress notes dated 09/18/22 written by V6, Registered Nurse, documents in part: 2:05 AM- Patient pulled the call light, assigned nursing assistant went to answer the call light and to turn off the light, patient refused the assigned nursing assistant to turn off the light and requested to see the RN immediately. RN went into the patient room immediately, patient verbalized I accidentally injured myself with a scissor take me out of here patient words. Patient was observed with minimal bleeding in the right lower abdominal area with scissor laying on the superficial area of the abdomen. No other visible injury noted. At 2:08 AM- Called 911. At 2:25 AM- 911 arrived; patient taken to Local Emergency Department (ED). On 10/12/22 at 10:15 AM, in the presence of V1 Administrator and V2 Director of Nursing, R1 showed in his possession two sharp, pointed grooming scissors, and a box of 4 stainless steel blades used for shaving at his bedside. On 10/12/22 at 1:48 PM, V6, Registered Nurse/RN in charge of R1 at the time of the incident stated the last time I saw R1 during my shift on 9/18/2022 was around 12:00 AM when R1 came to the nursing station to ask me (V6) for a PRN (as needed) pain medication. V6 stated I asked R1 to rate his level of pain and R1 reported his pain level to me (V6). V6 stated I proceeded to administer the PRN pain medication to R1 and R1 returned to his bedroom. V6 stated at about 2:00 AM, the CNA\Certified Nursing Assistant requested I come into R1's room. V6 stated when I arrived at R1's room, R1 stated he had injured himself. V6 stated R1 showed me his abdomen where I (V6) saw a pair of scissors stuck in his abdomen. V6 stated I asked R1 what are you doing with scissors and R1 stated I use them to trim my mustache. V6 stated R1 said I did not know the scissors were in the bed when I tried to roll myself over and the scissors got stuck in my abdomen. V6 stated the scissors were left in R1's abdomen when R1 was transported to the hospital via ambulance. V6 stated R1 has never requested assistance from me (V6) regarding grooming. V6 stated R1 does require assistance with grooming. On 10/12/2022 at 11:03 AM, V3 Director of Nursing/DON, stated that R1 does not need help with shaving and beard/mustache trimming. V3 also stated that after the incident, she did a whole house sweep to check if any residents have any scissors, razors, blades and other hazards at the bedside and documented on a log that the residents had no sharps located in their possession. V3 stated R1 is able to trim his mustache, R1 is alert and oriented times three. V3 stated R1's BIMS (Brief Interview for Mental Status) score is 14. V3 stated R1 is able to make his needs known to staff. V3 stated the trimming of R1's mustache/beard is a part of grooming and R1 has been coded on the MDS (Minimum Data Set) as requiring assistance with grooming. V3 stated R1 has the following mental health conditions: Conversion disorder, Depression and Anxiety Disorder. V3 stated it is not safe for R1 to have scissors at R1's bedside. V3 stated the nursing staff should be completing rounds on each resident every two hours. V3 stated that R1 did not have any scissors, blades or any hazardous materials at the bedside anymore. V3 also stated that R1 was educated on the importance of asking staff for assistance if he needs to trim his beard/mustache and shave his face. On 10/12/2022 at 11:42 AM, with V1(Administrator) and V3 (DON\Director of Nursing), R1 was observed with two pairs of sharp, pointed grooming scissors, a box of 4 double sided steel blades used for shaving inside a black grooming kit bag. R1 stated he has had the grooming scissors since he first got admitted in the facility about 2 months ago. R1 stated nobody checked his belongings when he got admitted . After the incident, when he came back from the hospital on 9/21/22, R1 stated that nobody told me I shouldn't have any scissors in my room, nobody checked my belongings, nobody educated me to ask for assistance if I wanted to use scissors to shave and trim my mustache\beard. R1 stated I have been using the scissors or razor blades since I was readmitted into the facility. On 10/13/2022 at 10:07 AM, V7 (CNA\Certified Nursing Assistant) stated R1 has never asked me for assistance with grooming. V7 stated I did not know R1 had grooming scissors in R1's room. V7 stated I (V7) don't feel that it is safe for any resident to have sharps or scissors in their possession in their rooms. On 10/13/2022 at 10:09 AM, V8 (CNA\Certified Nursing Assistant) stated, R1 is very independent, R1 has never requested help from me (V8) with assisting in grooming himself. V8 stated I (V8) have witnessed two residents with scissors in their possession before we had the in-service about inventorying a resident's belongings and removing sharp objects from a resident's room. V8 stated the in-services on completing an inventory of a resident's belongings and removing sharps from a resident's possession where both given on 9/19/2022. V8 stated after the in-service staff did remove the scissors from out the two resident's rooms. V8 stated I do not think it is safe for residents to have scissors or sharps in their possession. On 10/13/2022 at 10:50 AM, V12 (CNA\Certified Nursing Assistant) stated I(V12) don't think it is safe for any resident to have sharps or scissors in their possession. On 10/13/2022 at 11:03 AM, V13 (CNA\Certified Nursing Assistant) stated, I was doing rounds for my assigned residents, it was past midnight, R1's call light was on, so I answered R1's call light. V13 stated when I arrived in R1's room, R1 was yelling at me to get the nurse because R1 did not want any other staff to look at his injury. V13 stated, I (V13) went to get the nurse immediately. V13 stated, when I (V13) returned to R1's room with the nurse, the nurse and I saw a pair of scissors laying laterally in R1's stomach and the handle of the scissors was sticking out of R1's abdomen. V13 stated, I asked R1 what happened and R1 stated he rolled over and the pair of scissors got into him. V13 stated, I have not seen R1 with scissors before this incident occurred. V13 stated, R1 left going to the hospital with the pair of scissors embedded in his (R1's) abdomen. V13 stated, after R1 left going to the hospital we did a sweep of R1's room and the staff did not find any other sharp objects. V13 stated, I work the overnight shift and R1 has never requested assistance from me with shaving or trimming his mustache. V13 stated, I have not received an in-service from staff regarding supervising residents with razors or scissors. R1's Hospital records dated 09/18/2022 under History and Physical documents in part: After trimming his beard, patient put blades on the table, his Air Pod case has a magnet, blade attached to the magnet, patient placed Air Pod next to him on bed and rolled with resultant abdominal stab. Patient stated pain, severe, brought to the ED (Emergency Department), initial images revealed a nonpenetrating stab. Surgery consulted; blades removed in the ED. Patient admitted for observation. CT of the Abdomen and Pelvis done at the hospital dated 09/18/2022 documents in part under Impression: Scissors embedded in the subcutaneous tissues of the right lateral anterior abdominal wall. No evidence of injury to the underlying bowel, musculature or vasculature. No active bleeding at this time. R1's hospital records dated 09/18/2022 under Past Surgical History documents in part, Procedure: 12/2019 Repair RLQ stab wound to abdomen. Patient states passed out and fell on scissors. On 10/12/2022 and 10/13/2022 interviews with V4, V7, V8, V9 and V10 all CNAs\Certified Nursing Assistants affirm that they did not have any knowledge that R1 had a pair of sharp, pointed scissors at the bedside. On 10/13/2022 at 11:24 AM, V15 (Restorative Director) stated R1's MDS (Minimum Data Set) dated 10/06/2022 Section G. Personal Hygiene was coded for Limited assistance. V15 stated, I (V15) coded R1 like that because R1 needs cueing, R1 needs assistance. V15 stated, the CNAs\Certified Nursing Assistants are encouraged to assist R1 or to ask R1 if they can provide assistance to R1 with R1's personal hygiene needs due to R1's medical condition. On 10/17/2022 at 4:00 PM, V16 (R1's Primary Care Doctor) stated, R1 was strongly recommended to see a psychiatrist due to behaviors R1 was having. V16 stated, R1 was seeking pain medications more often and being rude with staff when R1 did not receive the pain medications from staff. V16 stated, R1 requires supervision when using scissors or blades for shaving. V16 stated, surgery was not required to remove the pair of scissors from R1's abdomen. V16 stated, R1 is not safe to use scissors and blades independently and should not have scissors or blades at the bedside. V16 was asked by the surveyor if someone like R1 with diagnosis of seizures, psychiatric diagnosis such as major depression, anxiety, post traumatic stress disorder and behaviors such as medication seeking behaviors, should have hazards at the bedside and use sharp pointed scissors independently, V16 (R1's PCP) stated no, R1 requires supervision with using such items as scissors or shaving blades. POS (Physician's Order Statement) affirms R1 is receiving [MEDICATION(S)] and Aspirin and is at risk for bleeding and bruising due to anticoagulant use according to Care Plan dated 09/01/2022. Face sheet affirms R1 has diagnosis (Dx) of Seizures and psychiatric dx which include Major Depressive Disorder, Anxiety Disorder and Post -traumatic stress disorder. R1's care plan affirms he has narcotic seeking behaviors, maladaptive behavior and factitious\conversion disorder. Reviewed R1's care plan dated 09/01/2022 documents in part, Focus: R1 has an ADL Self Care Performance Deficit and Impaired Mobility related to lower extremity Paralysis, [CONDITION(S)], B/L weakness and numbness, chronic back pain, [CONDITION(S)] and [CONDITION(S)] affecting left dominant side. Goal: R1 will maintain his current self-care and mobility status through next review. Interventions: Personal Hygiene/Oral Care: R1 requires (1) staff participation with personal hygiene and oral care. Focus: I have [CONDITION(S)] Disorder. Goal: I will be free from injury from [CONDITION(S)] activity through next review date. Intervention: [CONDITION(S)] Precautions: Do not leave resident alone during a [CONDITION(S)], protect from injury, if resident is out of bed, help to the floor to prevent injury, remove or loosen tight clothing, don't attempt to restrain resident during a [CONDITION(S)] as this could make the convulsions more severe, protect from onlookers, draw curtain etc. Focus: Narcotic Seeking. I exhibit on-going pathology including medication seeking behavior. I may express untruthful pain assessment with exaggerated perception of pain. I am diagnosed with conversion disorder (d/o). I seek narcotics on a regular basis. I have demonstrated poor response to education explaining the physical/mental dangers of addiction (I know what the outcome will be). Behavior includes attempting to manipulate the nurses for additional medications, even requesting that nurses call my MD. I engage in histrionic behavior such as throwing myself on the floor. Clinical interviews and records indicate that this has been going on for a long period of time. I am caught in a cycle of addiction, but I do not acknowledge this. At this time, I will not take the first step towards recovery by recognizing the addiction problem. Goal: I will acknowledge my opiate addiction and work with IDT to engage in counseling through the next review. Intervention: Educate resident on the physical and psychological dangers of addiction. Counsel and remind the resident to refrain from asking for medication that is unnecessary and not prescribed for their use. Use phrases such as I will not have that discussion with you or You need to address your medication questions to the doctor if/when the resident asks for additional narcotics or increased dosages. Remind\instruct the resident to have all medication discussions with the doctor, not the floor nursing staff (who do not prescribe). Focus: Maladaptive Behavior. I am an adult living with significant medical, mental health (conversion d/o) and addiction. I display little to no insight. I display socially inappropriate and maladaptive behavior including trying to subtly or discretely video record my caregivers. I demonstrate mood liability. Showing little ability to self-regulate anger/temper and mood state. I make irrational requests to call 911 when I am not experiencing a crisis. Goal: I will have no further episodes of using my cell phone device to record my care partners nor will I intentionally slide from my chair. Intervention: Conversion d/o related behavior. If R1 states he has extreme pain or is passing out listen to him and provide consistent medical evaluation/treatment. This may also be R1's way of saying he does not want to engage in therapy. Encourage him to work on his mental health issues with the clinical therapist. Focus: Factitious Conversion Disorder. I present with signs/symptoms of conversion d/o. I display excessive anxiety and I allow myself to reach a state of dysregulation. I ask (or demand) that the nurses call 911. I believe I am having an emergency. I do not need hospital care, but I insist I am in crisis. I demonstrate limited self-awareness and do not recognize how my behavior is detrimental. Symptoms include Poor engagement in psychiatric or psychological evaluation/treatment, sabotaging my care plan or suddenly becoming more ill and seeking powerful narcotics. Goal: I will seek mental health treatment, engage in self-improvement goals and have no further incidence of asking nurses to call the 911 system when an emergent crisis does not exist. Intervention: Psychiatric and psychological evaluation and treatment, as indicated. Promote therapy working to resolve underlying psychological issues that may not be causing the behavior. Meet with these providers to discuss best systems and best approaches for working with a person with a conversion disorder. Encourage the resident to work with the therapist on permanent behavior change, reducing or eliminating negative and troubling coping patterns and replacing them with positive life-fulfilling behavior. Focus: R1 has potential for bruising, hemorrhage due to anticoagulant use. Goal: R1 will remain free of hemorrhage and/or bleeding. Interventions: administer medication as ordered and monitor for adverse or allergic reaction, call MD for any changes in condition. R1's care plan was not updated following incident on 9/18/2022. On 10/12/2022 facility did not provide evidence of providing education to R1. On 10/18/2022 reviewed the following Policies: Policy titled Hazards Adopted 7/28/2016, reviewed\revised 7/28/2022 Policy Statement documents in part, it is the facility's policy to ensure the safety of each resident in the building and remove hazardous items and correct situations to prevent accidents. Procedures 1. Ensure that residents have no access to medications, sharps, and chemicals that would be hazardous to them. Policy titled General Care Adopted 11/21/2016, Reviewed/Revised 7/28/2022 documents in part, Policy Statement: It is the facility's policy to provide care for every resident to meet their needs. Procedures: 1. Upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs. Physical needs would include, but are not limited to ADL, wound care, medical needs etc. Psychosocial needs would include but are not limited to areas of mental and psychosocial well-being. 10/18 2022 review of Certified Nursing Assistant's job description documents in part, underneath duties and responsibilities: d. assisting with and/or performing the shaving, oral hygiene, nail trimming, toileting, etc. of the resident. 2. Assists in and performs specific techniques of personal care under the direction of the professional staff. The surveyor on 10/18/2022 via observation, interview and record review confirmed the following removal plan was implemented by the facility: 1. On 10/12/22, R1 was assessed by Occupational Therapy and was deemed to be needing supervision with grooming and personal care. 2. On 10/12/2022 at 11 am, the facility conducted a house wide sweep to identify if any residents have any sharp items at the bedside. None were identified. 3. On 10/12/2022 the Administrator and Designee re-inserviced direct care staff and all employees to ensure there are no sharp items at the bedside. Any sharps found must be secured in a locked cart at the Nurses station. Residents who are deemed able to use the personal grooming items must be provided staff supervision for safety. 4. A revised inventory checklist was implemented for all (1) newly admitted , (2) readmitted residents and (3) current residents having new items brought into the facility, to ensure no sharp items are identified, and if any that they be removed and kept in the locked cart at the nurse's station and or returned to family. 5. All residents were notified individually by the IDT regarding no sharp items at bedside and that all belongings brought into the facility need to be brought to staff and itemized on the personal inventory checklist. This was initiated on 10/13/2022 and completed on 10/14/2022. 6. An informational sheet was added to the admission packet for all resident/families informing that all items brought into the facility will be brought to staff and inventoried and that no sharp items are to be brought into the facility. 7. Inventory checklist sheets will be completed by the nursing staff in the facility. The revised inventory checklist was initiated on 10/13/2022 and is ongoing. 8. Newly hired employees will be educated during orientation and Agency Staff will be educated during the start of the shift with the Updated ADL Policy to ensure no sharp items are kept at bedside and that all personal belongings brought in are inventoried and checked for sharp items. 9. The facility ADL Policy has been updated on 10/13/22. Attachment # 4j was added to ensure all residents are provided supervision during ADL care with the use of razors, scissors and any sharp items at all times. No residents will be allowed to use any sharp items without the staff supervision for safety reasons. 10. QA Tool will be initiated on 10/14/22 by the Administrator and Designee to check 3\week x 12 weeks to ensure there are no sharp items at the resident's bedside and to ensure that residents received supervision for grooming for safety. 11. Medical Director was notified via telephone of the F689 IJ findings and the QA Committee reviewed the Abatement Plan and approved on 10/13/22.

Based on interview and record review, the facility failed to monitor and assess a change in condition for one resident (R1) reviewed for change of condition. This failure resulted in R1 going into septic shock requiring hospitalization and critical care. Findings include: R1's medical record (Face Sheet, Progress Notes) documents is a [AGE] year-old, admitted to the facility on [DATE] following L3-L4 decompression arthrodesis, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set, 02/24/2022) documents R1's Cognitive Skills for Daily Decision Making as independent-decisions consistent/reasonable. R1 requires extensive assistance with transfer and toilet use. Skin/Wound Note (02/17/2022) documents in part: 1. Left flank area proximal, surgical -0.6 x 6.6 cm -Surgical incision approximated and remains free of s/s (signs/symptoms) of infection or drainage -No c/o (complaint of) pain or discomfort 2. Left flank area, distal surgical -0.8 x 1.1 cm -Surgical incision approximated and remains free of s/s (signs/symptoms) of infection or drainage -No c/o pain or discomfort 3. Left elbow, dry scab -0.3 x 0.3 cm -No drainage noted -No odor noted -No c/o pain or discomfort 4. Upper back noted with soft bump 5. Blanchable redness noted to bilateral heels 6. Spider veins note to bilateral feet 7. Old surgical scars noted to R (right) knee, mid lower back, right mid abdomen, and left upper chest 8. Skin tags noted to left mid abdomen, and symphysis pubis 9. Bruises noted to r(ight) antecubital area, and left dorsum 10. Dry skin noted to bilateral lower legs Resident is continent of bowel and bladder On 02/24/2022 R1 was sent to hospital; R1 received fluid resuscitation (rapid administration of IV fluids to correct fluid volume imbalances), intubation (insertion of tube into the airway to aid with breathing), and administration of pressors (medication to elevate blood pressure). R1 underwent emergent debridement (surgical removal of dead, devitalized or contaminated tissue) on 02/24/2022 for Fournier's Gangrene (a type of flesh-eating disease that affects the scrotum, penis or perineum); additional debridement on 02/26/2022, and diverting [CONDITION(S)] (a surgical procedure in which one end of the large intestine is diverted through an incision made in the abdominal wall) on 03/07/2022 to aid in wound healing. On 02/24/2022 at 9:43 AM, V3's progress note documents BP: 102/50, HR: 98 On 02/24/2022 at 2:54 PM, V5's (DO) progress note documents in part: Seen with NP (Nurse Practitioner) today and patient reports new onset bowel/bladder incontinence. States that LLE (left lower extremity) weakness remains the same, denies saddle/perineal anesthesia. Drowsy due to meds. EXAM: VSS (vital signs stable), distress. On 02/24/2022 R1's ambulance run sheet documents ambulance was dispatched to nursing home (arrived on scene at 12:34 PM) for transport of R1 to ER (emergency room ) for new bowel and urinary incontinence after lumbar fusion. Pain to low back and new pain to left abdomen (6/10 on pain scale). States (R1) feels weak. Blood pressure range: systolic 97-85, diastolic 60-55 (lowest blood pressure was 85/55). IV started, 250 cc NS (normal saline) given. Arrived at hospital at 1:25 PM. On 02/24/2022 at 1:59 PM, R1's ED (Emergency Department) Notes document in part, Per patient, reports (R1) has been incontinent x2 for the past 3 days, had problems with urination after lumbar fusion and had (indwelling urinary catheter) in place that was (discontinued). Patient states discomfort to lower abdomen, also having LBP (low blood pressure). Also has testicular (bilateral) swelling that is tender to touch. On 02/24/2022 at 12:00 AM, R1's Procedure Notes documents, in part, (R1) is a [AGE] year-old with noted (Fournier's Gangrene) by ultrasound, CT, and exam. I immediately called in the OR team. Physical exam was consistent with (Fournier's gangrene). Dead and necrotic tissue was removed. On 02/25/2022 at 6:38 PM, Consult Notes document in part, In the ED on arrival, patient found to be hypotensive (low blood pressure) with BP as low as 77/50. Patient received 3l n/s (normal saline) bolus (a large volume of fluid given intravenously to hasten a response) in ED, but BP remained low despite fluid resuscitation, so central line placed and patient initiated on pressors. On 03/08/2022 at 10:10 AM, R1's Consult Notes document in part, On 02/24/2022, (R1) was seen in Emergency Department for urinary retention and abdominal pain and was subsequently admitted for [CONDITION(S)] related to Fournier's Gangrene as noted on the CT of the abdomen and pelvis requiring emergent operative debridement. (R1) was admitted to the ICU, intubated on pressor support and IV antibiotics. (R1) returned to the operating room a few days later as the necrosis had extended posteriorly to (R1's) rectal area requiring further debridement. On 03/07/2022, (R1) underwent a diverting [CONDITION(S)] in an effort to facilitate further wound healing. On 06/29/2022 at 8:00 PM, R1 said, I had surgery on my back on 02/15/2022. I was discharged to (Nursing Home) on 02/16/2022. They removed the catheter (indwelling urinary) at (local hospital). I wasn't able to use the toilet at facility; I needed help to stand up. They gave me a urinal to use. I was left in diapers for prolonged periods of time, that's what I felt. It was hard to use the urinal with the diapers. I complained about having a painful rash to my crotch and I felt like I had a bladder infection because I had to urinate, and nothing would come out. I complained to staff about it around the 19th or the 20th (of February). I sent at least three messages via the patient portal, to V5 (DO/Doctor of osteopathic medicine) or V18 (Neurosurgeon), with my concerns around 21st of February. They (Physical therapist) put me on a stationary bike, and I told the therapist you have to stop this because it's irritating me (discomfort to scrotal area). On 06/30/2022 at 10:38 AM, R1 said, I sent the first message to V18 on 02/17/2022 at 10:53 PM, 'This place is the pits. I've only had one PT (Physical Therapy session). I'm getting a lot pain in the right leg and I've had to ask for pain medication and no shower.' On 02/21/2022 at 9:55 AM, V19 (PA-Physician Assistant) responded, I'm just checking if you're having a better experience at the nursing home. Are you getting PT? Have you been showered? Is your right leg getting better? At 3:50 PM, R1 responded, not able to take shower. I have painful skin rash from diapers, not helped with bladder issue (couldn't urinate but felt urge), they have not offered rash cream yet. At 3:56 PM, R1 responded, PT session very short. R1 states the message was viewed by staff on 02/21/2022. R1 said, It was painful, I could feel it, it was in the crotch, it was from the diaper, it started around 02/20/2022 or 02/21/2022, that's when I first asked for rash cream. V18 (Neurosurgeon) and V19 (PA) were not available for interview. R1's progress notes do not document R1's aforementioned complaints. On 06/30/2022 at 1:28 PM, V5 (DO) said, (R1) is status post [MEDICAL RECORD OR PHYSICIAN ORDER] . When I saw (R1) at the nursing home, (R1) was altered, (R1) had altered mental status and wasn't answering appropriately. (R1) was incontinent, I was concerned that he could have had an impingement (compression of spinal nerves resulting in numbness and tingling). I wasn't notified (by nursing home staff) that (R1) was incontinent. There was no timeline. (R1) could have been incontinent for a few minutes. I saw (R1) but I couldn't say (if I examined R1), an exam took place, but I couldn't say it was a head to toe. I didn't know at the time that (R1) was septic (septic shock is a severe complication of [CONDITION(S)] that can include very low blood pressure, an altered mental state, and organ dysfunction). On 06/30/2022 at 3:30 PM, V3 (LPN) said, (V5, DO) assessed (R1). (V5) asked me what (R1's) baseline was, did (R1) have any complaints? I (V3) said, 'Doc, to be honest, at the beginning of my shift, I did (R1's) vital signs, (R1) had no complaints, I offered (R1) pain medication.' I didn't know if (R1) was telling the truth. I had to be honest to the doctor. I didn't know if (R1) was incontinent or not. My CNA (Certified Nursing Assistant) reported to me that (R1) was incontinent. (V5) wanted (R1) sent to the hospital right away, that means the same day, today. I completed my med pass, then did my note and called (Private Ambulance). I finished my med pass around 10:30 AM. (R1) was picked up in the afternoon. I'm pretty sure that I started (R1's) paperwork then. To be honest, I didn't know it was serious. I asked the doctor why I had to send (R1) out. I didn't know what (R1's) baseline was before; I didn't know if (R1) was telling the truth (about incontinence). I did assess (R1) before (R1) left (assessment I consisted of vital signs only). I don't really touch the patients. I give their meds, check vital signs, give pain med if they ask for it, and of course tell the doctor what's going on. I held one medication ([MEDICATION(S)]) because (R1's) blood pressure was low. I mentioned this to (V5,DO); (V5, DO) didn't really say anything.

Based on observation, interview and record review, the facility failed to ensure that a pressure sore did not increase in size/decline and failed to ensure proper functioning of low air loss mattress for one (R3) of four residents reviewed for pressure ulcers. These deficient practices resulted in deterioration of R3's sacral pressure ulcer , developing to a Stage 3 pressure ulcer. Findings include: On 09/19/19 at 10:45 AM, R3 was observed in bed, asleep, turned to her right side with a pillow placed under left shoulder and lower back. R3 is using a low air loss (LAL) mattress . Her LAL mattress was covered with a fitted sheet. Under her lower back, a white blanket folded into fourths was observed placed. On top of the folded white blanket, an orange disposable under pad was also placed. R3 has a [DIAGNOSES REDACTED]. According to R3's Skin/Wound note, the following were documented: 04/12/19 - sacrum Stage 2, measurement of 2.9cm (centimeters) x 3.7 cm x 0.1cm 05/24/19 - sacrum, measurement of 3cm x 4cm x 0.2cm 05/31/19 - sacrum Stage 3, measurement of 4.2cm x 3.0cm x 0.3cm 09/09/19 - sacrum Stage 3, measurement of 1.7cm x 1cm x 0.4cm 09/13/19 - sacrum Stage 3, measurement of 2.3cm x 1cm x 0.2cm Wound Care plan revised date 08/03/19 documented: Sacrum: Stage III - R3 is on air reducing mattress - date initiated 09/10/19. On 09/23/19 at 12:15 PM, V6 (Registered Nurse, RN) was asked regarding interventions in preventing the deterioration of R3's pressure ulcer on the sacral area. V6 stated, I am the regular nurse for R3. When I do my rounds, I have to make sure that I check her for any unusual skin condition. I make sure she is dry, turned and repositioned every two hours. She is using a LAL mattress, a flat sheet needs to be covering the mattress. Fitted sheets should not be used because it prevents the alternating pressure in the mattress. Only one flat sheet is to be used to cover the mattress all the time. At 12:34 PM, V8 (Certified Nurse Aide, CNA) was also asked regarding R3's pressure ulcer. V8 stated, She has a pressure ulcer in the sacral area, so she needs to be turned and repositioned every two hours, make sure she is always dry. She is using a LAL mattress, With this special kind of mattress, we only use one flat sheet to cover the mattress, not a fitted sheet, because the circulation in the mattress is compromised. There should be no double padding, just one under pad under her lower back. She wears an incontinent brief too. At 12:55 PM, V10 (Licensed Practical Nurse, LPN/Wound Care Coordinator) was interviewed regarding the use of LAL mattress in the management of pressure ulcers. V10 stated, Upon Admission of residents in the facility, if they are high risk to develop pressure ulcers, we put them on low air loss mattress. We in-serviced the staff on the floor regarding protocol for the LAL mattress, which is to use one flat sheet only, not fitted sheet because fitted sheet alters the pressure hindering the expansion of the mattress. We can put one draw sheet but no bed pad underneath. We cannot use blankets folded into two or four, placed underneath residents' lower back. At 3:29 PM, V12 (Wound Physician) was asked regarding R3 and prevention and management of pressure ulcers. V12 stated, I make rounds in the facility every week. I expect staff who sees the residents daily to identify individuals who need low pressure mattresses, heel boots and determine how to prevent pressure ulcers. A LAL mattress is a low pressure mattress, soft on skin and avoids pressure on pressure points like hips and lower back. The use of LAL mattress is the one helping in the prevention and management of pressure ulcers. I think if placing multiple sheets on the LAL mattress and if it is done repeatedly, it may worsen a pressure ulcer. Yes, I am aware that her (R3) pressure ulcer worsened into Stage 3, she is very rigid in terms of turning and needs two person assist, very limited. So, the LAL is the one helping the pressure ulcer. On 09/24/19 at 1:19 PM, V2 (Director of Nursing) was interviewed regarding prevention and management of pressure ulcers. V2 verbalized, I expect the staff to follow protocol regarding skin: turning and repositioning of residents, keeping residents clean and dry, use of LAL mattresses, report to the nurse immediately if they see any skin changes so we could take action right away. With the use of low air loss mattresses, a single drawsheet is to be used. Facility's policy titled, Pressure Ulcer Treatment Protocols, undated, documented in part: Policy: All residents with pressure ulcers will be treated with consistent treatment protocols to aid in the healing process. Recommended Treatment Options: Stage III/IV: Treatment: 4. Pressure Reducing specialty mattress Facility's policy titled, Air Mattress, undated, documented in part but not limited to the following: Purpose: 2. To alleviate constant pressure on pressure points; 3. To aid in prevention and/ or healing decubiti. D. Procedure: 4. Care of resident on air mattress d. Avoid use of heavy padding (one disposable under pad or cloth incontinent brief may be used). Hinders benefit of mattress.

Based on interview and record review, the facility failed to conduct a follow up assessment of the change in eye condition and failed to follow the facility skin assessment policy and conduct a skin assessment every other day for 1 of 3 residents (R1) reviewed for quality of nursing care. These failures resulted in R1's eye swelling and redness worsening and R1 being sent to the hospital for evaluation. R1 was admitted and treated for [REDACTED]. Findings include: R1 was admitted to the facility on [DATE], according to R1's facesheet. R1 was transferred to local hospital on [DATE]. On 2/28/17 at 12:46pm, Z1 (emergency room Nurse) stated that R1 arrived to the local hospital's ER (emergency room ) on 2/17/17. Z1 stated that R1 had so much discharge and blood coming from both eyes that R1 was not able to open them. R1's skin around the [MEDICAL CONDITION] site was reddened and they were ruling out infection. Z1 said R1 also had wounds on the thighs. The doctors wanted R1 to be sent to another hospital to be assessed and evaluated for [MEDICAL CONDITION] the thigh area. R1's conditions needed to be treated at a hospital with higher level care. Review of R1's Emergency Physician Exam from (Hospital A) dated 2/17/17, documents: R1 had conjuctival infection, lid inflammation, and exudate (fluid) in both eyes. An ostomy with erosion and [DIAGNOSES REDACTED] (redness) of the mucosal surface with leaking of enteral contents. Pelvic exam revealed [DIAGNOSES REDACTED] and inflammation to vaginal mucosal tissue. R1's Emergency Physician Evaluation dated 2/17/17 documents: not comfortable keeping patient at this facility without specialized wound care, recommend that patient be transferred to tertiary care center with burns. R1's Transfer Form indicates resident was sent to a different hospital on [DATE]. Review of R1's Admission History and Physical (Hospital B) documents in part: Eyes are crusted. Rash around [MEDICAL CONDITION] bag and right upper inner thigh. On 2/27/17, E2 (Director of Nursing) presented R1's Clinical Notes Report for review. R1's Nursing Daily Notes (dated 2/4, 2/7, and 2/12/17) documents, per E4 (RN), the following: [MEDICAL CONDITION] bag changed and care rendered, discolorations around the site and small abrasion noted. No further documentation on these dates, reveal notification to the Physician or Nurse Practitioner. On 3/1/17 at 3:54pm, E4 stated, a head-to-toe assessments are done with every shower (2-3 times a week) and documented on the shower sheets by the CNA's (Certified Nurse Assistants). Nurses are required to document in the Nurse's Notes. If there is discoloration to the skin, we report it to the supervisor and make an incident report, inform the family and notify the doctor. R1's physician progress notes [REDACTED]. Will order Artificial Tears twice a day. No subsequent or follow up regarding R1's eyes documented per nursing staff from 2/10/17-2/17/17. On 2/17/17, Z2 documented, Patient's eyes with more yellow drainage and crustiness, appears to worsened since the last week. Increased eye lid [MEDICAL CONDITION]/purulent drainage now with photophobia (discomfort or pain to the eyes due to light exposure) /crustiness (dryed discharge). On 3/2/17 at 11:40am, surveyor inquired to Z2 regarding treatment plan for R1's eyes that was noted with yellow crustiness. Z2 stated, I continued R1 on Artificial Tears because it was just crustiness on the eyelids. R1's Wound Care Consult from (Hospital A), date of service 2/17/17, reveals: Female genitalia with mirror image wound on bilateral inner thigh that is covered in eschar (dead tissue) and painful to palpitation. R1's Braden Scale assessment dated [DATE] documents resident as moderate risk level. On 3/1/17 at 3:52pm, E5 (Wound Care Nurse) stated, head-to-toe assessments are done every other day on residents who are considered moderate risk according to the Braden Scale (Pressure ulcer risk). Rashes, wounds, and bruises are documented on wound care notes. R1's Wound Care Addendum notes reviewed (12/6/16, 1/2/17, 2/11/17, and 2/17/17). Revealed no documentation regarding R1's wounds on inner thighs. On 3/2/17 at 1:20pm, Z3 (Wound Care Physician) stated I was called to see R1 for the 1st time since resident was admitted here. The initial concern from the staff was involving a facial rash. Then I noticed that R1 would not open eyes. If R1's eye condition was bacterial or [MEDICAL CONDITION], we are now looking at [MEDICAL CONDITION]. DTI (Deep tissue injury) starts because of pressure. First it starts as discoloration, then becomes dark, then eschar tissue. Eschar tissue develops over time. The nurse notified me to consult on an elbow wound, I was never notified of any wounds to R1's inner thigh. On 2/27/17 at 1:37pm, E3 (Registered Nurse) transferring R1 to hospital, stated R1 had yellowish drainage on both eyes on 2/17/17. On 2/14/17, the [MEDICAL CONDITION] site had redness on it. When I came back to work on Friday 2/17/17, I noticed more redness at [MEDICAL CONDITION] site. On 3/2/17 at 3:30pm, E2 stated, the CNA's should notify the nurse with any new skin changes. Z2 was notified late regarding R1's [MEDICAL CONDITION] site. Z2 was not notified until 2/8/17. It is a given that when you notice any new skin changes, you notify the Doctor or NP. Regarding R1's eyes, it's just not documented (follow-up from the nurses). We might have just missed the wound on R1's thighs because we were so focused on the facial rash. Review of the facility's Skin Preventive Care Protocol (un-dated), indicates: B. Moderate Risk residents 2.) Resident will be checked for skin alteration daily during care. CNA to inform the nurse on duty with any skin issues. Nurse on duty will coordinate with wound care team for appropriate treatment. The facility's Wound Assessment Policy and Procedure (un-dated) indicates: Procedure: 3. A complete wound assessment will be done weekly or with significant change by the wound care team for all pressure ulcers, venous stasis ulcers, diabetic ulcer and skin tears. The facility's [MEDICAL CONDITION]/[MEDICAL CONDITION] Care policy (dated 7/16) documents: When evaluating the condition of the resident's skin, note the following: Signs of infection (heat, swelling, pain, redness, purulent exudate, etc.)

Based on observation, record review and interview the facility failed to safely turn of 1 of 8 residents (R1) reviewed for falls in a sample of 24 while providing care, causing R1 to fall . R1 subsequently sustained injuries and was sent to the local hospital via 911. The facility also failed to post oxygen signs to alert staff and visitors of oxygen use in the rooms of 1 sampled resident (R10) and 1 resident (R27) in the supplemental sample. Findings include: 1. On 11/14/11 during the initial tour with E13 (Registered Nurse, Minimum Data Set coordinator) R1 was lying in bed with a large bruise with swelling to the left side of the forehead, which contained a dressing over it. E13 stated that R1 had sustained a fall within the facility. The facility's Incident/Occurrence Report for R1 dated 11/10/11 documents that R1 sustained a fall which lead to R1 being sent to the hospital while receiving care from E10 (Licensed Practical Nurse) and E11 (Certified Nursing Assistant). The Incident Report also documents that R1 sustained a "big Bump" to the forehead with bleeding and swelling to the left shoulder. The physician's orders [REDACTED]. On 11/15/11 at 11:25am, (location- 4th floor)E11 stated that E11 and E10 was providing care to R1 prior to R1 going for dialysis. E11 stated that E10 turned R1 towards E11 and that E11 wasn't able to catch R1. E11 goes on to state "R1 was too heavy". E11 stated that R1 fell on top of E11 and they were both on the floor. E11 further states that R1 is not able to roll without assistance. E11 then stated that the men on the unit usually help, but were all busy and E10 offered assistance. E11 stated "it happened so fast." On 11/16/11 during the morning meeting with the facility at 10:10am (location-conference room), E17 (Corporate Director of Reimbursement) stated to the survey team that R1 is not able to roll over or turn to the side without staff assistance. E17 further states that R1 has not had a significant change in condition. On 11/17/11 at 10:55am via phone conversation, E10 stated that E10 was making rounds and noticed that E11 needed assistance with R1. E10 stated "we rolled R1 to the other side and R1 slipped." E10 then stated "R1's head went over 1st." E10 added that R1 has not been able to roll over or reposition without staff assistance since R1's last admission. The Minimum Data Set (MDS) for R1 with an assessment reference date of 9/01/11 documents: Section G, 1. ADL (Activities of Daily Living) self performance- A. Bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) Code 4 - Total dependence (full staff performance every time). B. Transfer (how resident moves between surfaces including to or from: bed) Code 4-Total dependence (full staff performance every time). The Patient information and Transfer Form for R1 from the local hospital back to the facility dated 11/11/11 documents the following major Diagnoses: [REDACTED]. 2. Room 214 was observed with a liquid oxygen container next to R10s bed. There was no oxygen hazards sign posted on the door. 3.Room 320 was observed with a large liquid O2 tank next to R27s bed . There was no oxygen hazard sign posted on the door. E1 ( administrator ) on 11/16/11 at 10:05AM in the conference room responded that all rooms containing Oxygen must be posted with Oxygen hazard signs.

Based on interview and record review, the facility failed to assess nature of fall and failed to put in place interventions after each fall to prevent 1 resident ( R3 ) in the sample of 14, from falling further. R3 sustained abrasion and pain during 4/1/11 fall and a dime sized cut at the occipital area of the head during 4/18/11 fall. Findings include : R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R3's incident reports showed that R3 fell on the following dates : 1) 1/31/11 at 345 PM - found sitting on the floor at the foot of the bed saying " I tried to walk but my legs are weak." Noted bruise on the left hand. Bed alarm and chair alarm was put in place and so as low bed. 2) 2/13/11 at 6 AM - R3 was noted in front of the wheelchair. R3 said that he was trying to pick up magazines on the floor and that he just slid down. Assisted back to wheelchair by 1 staff. 3) 3/14/11 at 7:15 PM - in room 314, staff heard the alarm and found R3 on the floor in sitting position, holding on to the bed rail. R3 verbalized he was trying to reach the phone and slipped off his wheelchair. 4) 4/1/11 at 7:30 AM - in room 309, a chair alarm was heard then a loud noise, R3 was found with left temporal and left neck area abrasion. R3's left side of the face was also reddened. Assisted back to wheelchair. said he was trying to reach for something. 5) 4/18/11 at 5 AM - in room 309, R3 was noted on the floor, on his back with arms on the side. Noted with dime-sized skin tear at the back of the head with minimal bleeding. R3 also complained of pain to the lower neck 6/10. Said he was trying to get to the bathroom by himself. Review of R3's medical record however, showed no indication each of the above fall had a post fall assessment or analysis. There was no indication of any note investigating why R3 fell on each of the above dates. E5 confirmed there is no post fall assessment sheet that the facility utilized for R3, although each fall is being discussed during each morning meeting by the IDT. Per R3's Falls care Plan originally started on 1/31/11, the chair/bed alarm, low bed reminder to use call lights, having proper shoes for transfer and walking, and education of resident were initiated on 1/31/11, in response to the initial fall on 1/31/11. When R3 fell again on 2/13/11, the new intervention put in place, was to do frequent rounds and keep R3 in common areas ( which was discontinued on 2/28/11). R3's fall on 2/13/11 though indicated that the resident said he slid down trying to pick up magazine on the floor. There was no investigation if the cause of fall was that, R3 slid down from the chair or while walking away from his wheelchair. There was no indication if the alarm was triggered or not, and why. The intervention was not really appropriate for the cause of R3's fall. On 3/14/11 and 4/1/11 falls, the alarm were all triggered, yet by the time staff got to R3, he was already on the floor. There was no post fall assessment again to determine real cause of fall, whether staff didn't hear the alarm initially, or was it the slow response time, or the alarm was just not effective. The 4/1/11 fall in fact was not even in R3's care plan, nor was there any indication, a new intervention was put in place on 4/1/11. The interventions for the 3/14/11 fall was a duplicate of the intervention for the 2/13/11 fall, which was to do frequent rounds and put R3 infront of nurses station. On 4/18/11 fall, there was no indication of an alarm triggered again. During 6/10/11 interview of E3 ( 11-7 nurse ), E3 could not even recall if an alarm was triggered or not. E3 also could not remember if R3 was in bed or in the chair, nor can E3 remember if she asked the CNAs if R3 was in bed or chair the last time R3 was seen prior to the incident. There was no indication as well, what new interventions were put in place since the chair and bed alarm had not been successful in preventing R3 from falling further since 1/31/11. It was not changed to address frequent fall which resulted to further falls. On 4/18/11, R3 sustained a dime sized cut at the occipital area of the head and a left temporal and left neck abrasion on 4/1/11 fall causing him pain.