Every finding on record at Haven of Douglas

Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident was free from preventable accidents including elopement. This deficient practice could result in life-threatening injuries.Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident was free from preventable accidents including elopement. This deficient practice could result in life-threatening injuries.Findings include: -Resident #100 was admitted to the facility on [DATE] with diagnoses that include acute respiratory failure, dementia, hypertension, anxiety, difficulty walking, and weakness. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating significant cognitive impairment. A care-plan revised July 30, 2025 revealed the resident has impaired cognitive function related to dementia with noted interventions that resident needs supervision and assistance with all decision making, and to keep resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. A behavior care-plan initiated October 20, 2025 revealed the resident actively exit seeks and makes multiple attempts to leave facility through alarmed doors, with noted interventions of monitor resident closely for any tailing of visitors as the leave the facility and redirect and reorient resident as needed and if appropriate. A wander risk evaluation dated October 16, 2025 revealed the resident was assessed with a score of 14, indicating a high risk for wandering behaviors. It further noted that resident has a known history of wandering at home prior to admission, and ambulation without assistance. A progress note dated October 16, 2025 at 8:31 a.m. revealed at 0800, Receptionist notified this nurse that this resident may have eloped from the facility. Receptionist stated, I was notified by a phone call from the community that it appeared to be one of our residents who was walking down the street. Resident's room was checked and dining room as well, the resident was not noted in either location. This nurse immediately notified all staff in the facility to assist with head count in the building and complete a facility sweep. Resident not accounted for. Staff search of surrounding area was conducted, and resident located several blocks away from the facility. When asked what she was doing, resident stated I am on my way to see the President. Resident was unharmed and not in distress. Resident was easily redirected to vehicle and driven back to facility without any signs or symptoms of acute adverse process or injury. Resident stated I was on my way to see the President. Resident was found and driven back to the facility with no issue. Head to toe assessment completed and no s/sx of injury noted. Resident has no c/o pain or discomfort at this time. Resident is A&0x1. Resident will be placed on q15 min wandering monitoring for safety. Resident is currently sleeping in bed with call light within reach and bed at lowest position. Care plan updated. MD, DON and Administration notified. Left voicemail to resident's husband/responsible party. A progress note dated October 17, 2025 at 8:30 p.m. revealed the resident continues to be monitored related to an elopement incident. No injuries or impairments noted this shift. Resident is alert and oriented A&Ox2 and is re-oriented and redirected as needed. Resident is currently in bed at lowest position with call light and water within reach. Safety mattress in place. An interview was conducted with a Registered Nurse (RN staff/#20) on October 23, 2025, at 10:58 a.m. The RN stated that during the shift where the resident eloped he got to the facility at 6 in the morning. He stated that he was doing wound care, and the other nurses were doing medication pass at about 8ish, he remembered seeing resident #100 when he went to the dining room. He stated that resident #100 said she was going for a walk and said I'll come back later. Staff #20 further stated it's normal for the resident to wander around the halls of the facility, but that a few minutes later the secretary at the front office notified him that a community member had notified the facility that the resident was walking down the street. He further stated that after doing a head count they went down the street to retrieve the resident who stated she was going to see the president. Staff #20 concluded that the resident did leave the facility and was returned, assessed and found to have no injuries. An interview was conducted with resident #100 on October 23, 2025, at 12:03 p.m. Resident #100 stated so far so good when asked about recent events, and that I'm still dealing with this one while pointing to an abrasion on her leg. The resident stated she doesn't know how it happened, that something was chasing her and she slipped and scraped her knee. Resident #100 stated she does not remember going for a walk, and that it was probably her sister that left. She concluded that she goes for a walk every day. However, it was noted the resident was a poor historian in the interview. An interview was conducted with the Director of Nursing (DON staff/#55) on October 23, 2025 at 12:20 p.m. The DON stated she was aware of the incident with resident #100, and that resident #100 was admitted from home several months ago because the family could no longer take care of her. The DON stated that resident #100 has Alzheimer's dementia, and was behavioral at home, had a fall resulting in a fracture at home, and that's how she ended up in the facility for rehabilitation services. The DON stated that resident #100's sister in law identified that she used to go for morning walks and that's why they had RNA doing supervised walks with the resident. The DON stated that she can't be 100% sure how resident #100 got out but since they didn't see her go out of the front door she thinks it was a side door with an alarm. The DON further stated that the alarm on the door was functioning and did trip the alarm, but that the alarm itself was too quiet for the staff to hear it because it was too quiet. The DON further stated that after the incident the resident was noted to have a urinary tract infection and that resident #100 was placed on 1:1 monitoring with a sitter to prevent further incidents. The DON concluded that it doesn't meet her expectations that the resident eloped and that the alarm was being replaced as part of all their interventions to assure this doesn't happen again. A review of facility policy titled 'Behavior / Mood / Cognition: Wandering and Elopements dated January 1, 2024, revealed that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. It further revealed that if a resident is identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to protect the rights of one resident (# 2) to be free from abuse by another resident (# 1). The deficient practice could result in other residents being abused. Regarding Resident # 1: Resident # 1 was admitted on [DATE], with diagnoses that included [NAME] Syndrome, adjustment disorder, and major depressive disorder.A care plan dated March 19, 2020, revealed that Resident # 1 exhibited behavior problems, including becoming very angry and agitated when another resident or roommate accidentally sits in his chair or accidentally touches personal items. The care plan also revealed that Resident #1 can become angry or agitated with other male residents who speak to my significant other. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident # 1 was unable to complete the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The assessment also revealed that Resident # 1 had physical behavioral symptoms directed toward others in the past 1 to 3 days.An incident note regarding Resident # 1, dated August 16, 2025 at 10:33 p.m., revealed that a Licensed Practical Nurse (LPN/staff # 5) was notified by CNAs about aggressive behavior towards another resident in his room. CNA staff informed the LPN that Resident # 1 was attempting to throw book and physically push the other resident. Staff were able to intervene, and the LPN (staff # 5) was able to separate the two residents. The incident also revealed that the LPN explained to Resident # 1 that their actions were wrong and to avoid them. The LPN described that Resident # 1 was argumentative but nodded when the situation was explained, as if Resident # 1 understood. The LPN also noted that he will continue to monitor.Review of the clinical record revealed no evidence that the incident was reported on August 16, 2025 to administration, family, provider or the state agency and there was no evidence of an investigation regarding the incident. However, during an interview, a Registered Nurse (RN/staff #22) revealed that the incident was reported to her, but she did not investigate as there was no injury.Further review of the clinical record revealed no evidence of additional monitoring after the August 16, 2025 incident.A Behavioral note regarding a second incident that occurred with Resident # 1 and Resident #2 on August 17, 2025. The note relayed that on August 17, 2025 at 4:27 pm, LPN (Staff # 8) heard screaming in the south hall. When staff arrived at Resident # 1's room, they saw Resident # 1 mad and screaming at Resident # 2. Resident # 1 then proceeded to place his hands-on Resident # 2's chest and pushed her out of the room, while Resident # 2 sat her in her wheelchair. Staff managed to separate residents. The LPN stated that he tried to educate Resident # 1 that he could not touch other residents. LPN # 8 did indicate notifying administration, and police. An Incident report regarding Resident #1, dated August 17, 2025 at 10:33 p.m. revealed that police had arrived regarding the incident, and a report was filed. The report revealed that the incident was unsubstantiated because there was no harm. The facility placed a Velcro barricade across the door. Regarding Resident # 2:Resident # 2 was admitted on [DATE], with diagnoses that included fracture of the left femur, dementia, atelectasis, and anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS score of 6, indicating severe cognitive impairment.Review of Resident #2's comprehensive care plan dated July 30, 2025, revealed that Resident # 2 had impaired cognitive function, dementia, or impaired thought process due to Dementia. Further review of the care plan revealed no evidence of a focus regarding wandering from July 10, 2025 through August 19, 2025.A Behavioral note regarding Resident # 2, dated August 16, 2025, at 7:03 p.m., revealed that Resident # 2 had been observed by Licensed Practical Nurse (LPN / Staff #5) entering many resident rooms. Resident # 2 had to be redirected over 10 times just by LPN Staff #5. The behavioral note revealed that Resident # 2 was unwelcome in many of the rooms and was aggressive to other residents when she was dismissed from their room. An incident note regarding Resident # 2 marked late entry dated August 16, 2025, at 10:30 p.m. revealed that at 6:00 p.m., Certified Nursing Staff (CNA) overheard a commotion in Resident # 1's room. Staff had entered the room and found Resident # 2 attempting to show Resident # 1 a book. The incident report also revealed that Resident # 1 became visibly upset by Resident # 2's presence, and that staff had to remove Resident # 2 from the room in which Resident # 2 obtained a skin tear, described as a 2 cm by 2 cm superficial laceration on her right forearm, which was cleaned and treated. Further review of the clinical record revealed no evidence that the skin tear was assessed by a nurse at the time of the incident on August 16, 2025, or that the incident had been reported to administration, provider or family.A second incident occurred between Resident #1 and Resident #2 on August 17, 2025, per an incident note dated August 17, 2025 at 5:41pm, late entry. Nurse and CNAs monitored the resident, and she was assessed for injuries.Review of the resident's care plan revealed a new focus regarding wandering that was initiated on August 20, 2025, after the incident. Interventions included offer activities, redirect when wandering the hallway, redirect and reorient when removing items from other resident rooms, redirect out of other resident rooms as needed.A facility investigation report signed August 22, 2025, unsubstantiated the August 17, 2025 incident due to no harm occurring, but failed to include any information from the August 16, 2025, incident.An attempt was made to call LPN # 5 on August 28, 2025, at 11:23 a.m., but was unable to reach and no phone call was returned. An interview with LPN # 8 on August 28, 2025, at 11:41 a.m., revealed that Resident # 2 wanders and goes into Resident # 1's room. On August 17, 2025, LPN # 8 revealed that he saw Resident # 1 wheel up to Resident # 2 and push her on the chest back out of his room into the hallway. Staff separated the residents, and LPN # 8 stated that he assessed Resident # 2, and she appeared to be ok. LPN #8 then stated he called the supervisors and was told to call the police. LPN # 8 was unaware of other altercations of Residents # 1 and 2 prior to the August 17, 2025, incident. An interview with CNA # 10 on August 28, 2025, at 1:43 p.m. revealed that she heard Resident # 2 had been wandering into Resident # 1's room and there was an altercation between the two. CNA # 10 reported that she was in the dining room when an altercation happened between Resident # 1 and # 2 on August 16, 2025, and helped make sure residents were separated from each other before going back to her section. She was unsure if that incident was reported, as usually the nurses will report incidents. An interview with CNA # 13 on August 28, 2025 at 1:52 p.m. revealed that on August 17, 2025, it was getting close to dinner time, and she heard some commotion from Resident # 1's room. CNA # 13 said she witnessed Resident # 2 get pushed by Resident # 1. It was revealed that Resident # 2 was pushed back into the hallway from Resident # 1's room by Resident # 1. CNA # 13 stated that they managed to get the residents separated and watched Resident # 2 closely to make sure she did not go into Resident # 1's room for the rest of the night. CNA # 13 was aware of the altercation between Residents # 1 and 2 on August 16, 2025, but was not working on that day. Attempted to Interview Administrator (ED/Staff # 18) on August 28, 2025, however, it was reported by staff that he was in Canada and they were unable to reach him at the time. Attempted to interview the Director of Nursing (staff #77) on August 28, 2025, but she was not available due to being out of town, and was unable to reach.An interview with both LPN Care Coordinator (Staff # 21) and Registered Nurse (RN/Staff # 22) on August 28, 2025, at 2:15 p.m. revealed that RN Staff # 22 was on call that weekend and received both calls for the incidents on August 16 and the incident on August 17, 2025. She revealed that the incident on August 16. 2025 was not physical and therefore did not report or investigate. When asked about Resident # 2's skin laceration Staff # 22 revealed that it was obtained while they were trying to remove Staff # 2 from the room and not caused by Resident # 1. Staff # 22 stated she had assessed the wound on Monday, August 18th even though the only skin and wound assessments on record were August 15, 2025, and August 22, 2025. Both assessments indicated no wounds to the skin. Staff # 22 revealed that they monitored the residents that night but did acknowledge that another altercation took place on August 17th, where Resident # 1 had pushed Resident # 2 out of his room. LPN Staff # 21 revealed that after the second incident, they had a meeting with Resident # 1 and family to set up outside psychological services. LPN Staff # 22 also revealed that they placed a Velcro barricade across Resident # 1's room to help prevent other residents from wandering in.A Policy and Procedure titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated January 1, 2024, stated the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy also revealed that the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment to protect residents from abuse by anyone including other residents and protect resident from further harm during investigations.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure that food items were stored and prepared under sanitary condition; and failed to ensure that expired food items were discarded. The deficient practice could result in unsafe food storage, placing residents at risk for foodborne illnesses.Findings include: During an initial kitchen observation conducted with the dietary aide (staff #70) on August 5, 2025 at 10:25 a.m. there were undated and unnamed Styrofoam meal box of 2 bologna sandwiches, bag of shredded cheese dated July 29 to August 1, 2025, a container dated August 4, 2025 with a hard boiled egg and an open Ziploc bag with cheese dated August 2, 2025. The dietary aide (staff #70) stated that the facility use 2 days from the day the hard boiled was cooked because there is no use by date for hard boiled eggs. The dietary aide then threw the Styrofoam meal box away and stated that there was no name or date on the Styrofoam box. At 10:31 a.m., the observation of the dry storage was conducted with the Dietary Manager (staff #23). The following items opened and with no opened/used by dates and were found in the dry storage area:-1 bag of hot dog bun; and,-1 large tub of mayonnaise.There was also 1 large tub of BBQ sauce dated July 16, 2025; but, it was noted whether it was the opened date or the used by date. The dietary manager stated that date on the tub was the opened date; and, the barbecue sauce did not have a use by date. There was also a box containing 6-7 heads of cabbage with multiple brown areas on the outside of each cabbage. The dietary manager stated that they would cut these cabbage in half to see the inside, but would not serve this to residents. The dietary manager stated that staff know what food had expired and what food items were still good in the refrigerator; and that, first date on the containers was when the food was made, and the second date was the use by or expiration date. Inside the freezer, there was 1 Ziploc bag of marinara sauce that had an expiration date of July 9, 2025; and, 1 Ziploc bag of cooked ham with an expiration date of July 17, 2025. The dietary manager stated that both the marinara sauce and the bag of cooked ham were expired. During an observation of the puree meal preparation with the dietary manager (staff #23) conducted on August 6, 2025 at 11:09 a.m., there were multiple flies found in the kitchen area, on the wall near the entrance to the refrigerator, on the tray line serving area and on the drink preparation area. The Dietary Manger stated that the administrator was aware of the issue and was trying to find a solution to the problem; however, the dietary manager does not know what the solution was. Further, the dietary manager stated that kitchen staff will kill the flies then wipe off the area where the fly was killed. An interview was conducted on August 7, 2025 at 8:50 a.m. with Infection Preventionist (IP/Staff #63), who stated the population served had an average age of 65, with weakened immune systems and age-related changes in the digestive system; and, it was very important that food was procured, stored, prepared, and served in sanitary conditions to prevent residents from becoming sick. Further, the IP stated that hand hygiene of kitchen of staff was important to prevent the spread of infection. The IP stated both he and the Dietary Manager (staff #23) provide in-services and audits in the kitchen to make sure kitchen staff were compliant; and, in order to prevent the spread of infection and bad bacteria, food had to be stored, and served properly and that outdated food should be discarded and not be in the fridge. The IP said that the Dietary Manager was responsible for refrigerator audits. Review of the facility policy titled Food Storage and Date Marking states Sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination.

Based on observations, resident and staff interviews and facility policy review, the facility failed to ensure the environment was free from pests. The deficient practice could result in the spread of germs. Findings included: On August 5, 2025 at 11:58 a.m. the resident was observed laying on his bed with a hat over his face. The resident was awake and stated that he put the hat on face because of the fly. A fly was observed flying around the resident's room and he stated that he has had flies in his room a couple of times. On August 6, 2025 at 11:09 a.m. multiple flies were observed on the wall by the refrigerator, on the tray line (serving area), and flying around in the kitchen, while observing the puree being prepared. The Dietary Manger (staff #23) stated that the administrator was aware of the issue and is trying to find a solution to the problem, but she was not aware of anything being done. She stated they will kill the flies, then wipe off the area where the fly was killed. During an interview conducted on August 6, 2025 at 12:06 p.m. with a resident (#24), a fly was observed on the resident's bedsheet and he was trying to shoo the fly away. On August 6, 2025 at 1:25 p.m., the resident's (#29) family stated that the flies were a problem and worse than normal today. He stated that he talked to the Administrator approximately two weeks ago about putting in air curtains on the outside doors which were used when he worked in a warehouse where food was stored. He stated that he was going to follow up with the Administrator about the flies. An interview was conducted on August 7, 2025 at 8:20 a.m. with the Administrator (Staff #34), who stated that the Maintenance Director was in charge of pest control, but his last day working for the facility was on Tuesday. He stated that the facility had a contract with a pest control company to spray the exterior of the building monthly and as needed. He stated that they get flies towards the end of the monsoon season and he was aware that this occurs during the season. He stated that there were fly traps at the edge of the property away from the building and they have told staff to limit exiting and entering the building through the courtyard to mitigate flies from entering the building. He has also reminded staff to keep food covered. He stated that the concern was reported to him on August 5, 2025. He stated that the pest control company does provide service for flies, but he has not contacted the company. He said that he was looking into ordering air curtains for the doors. During the interview, a small fly landed on the surveyor's hand. The administrator acknowledged that he was in charge of maintenance which included pest control at this time. The facility policy, Pest Control states that the facility shall maintain an effective pest control program.

Based on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that an allegation of exploitation for one resident (#24) was reported and investigated. The deficient practice could result in continued exploitation of residents. Findings include: Resident (#24) was admitted to the facility on [DATE] with diagnoses that included type II diabetes, acquired absence of unspecified leg below the knee, and chronic kidney disease. Review of the Personal Property Inventory list dated March 25, 2025 did not reveal that the resident had a cell phone. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident had a moderate cognitive impairment. Review of a grievance report dated July 28, 2025 revealed that the resident said that his phone had been missing since the weekend. The resident reported seeing another resident going into his room and his wallet and phone was then missing. The resident's room along with the facility was searched, but the phone was not found. The resident was to be reimbursed for the phone, but did not know the cost of the phone, but will let the Administrator know the cost of the phone. Review of the progress notes dated July 2025 did not reveal any documentation regarding the resident's complaint about his missing phone and seeing another resident in his room. Review of the Resident Relations Manager (Staff/# 71's) documentation revealed that she attempted to contact the resident's family member on July 28, 2025 and there was no answer, and twice on August 6, 2025 and left a message requesting a call back. The documentation did not reveal the reason for the calls. During the initial interview conducted on August 5, 2025 at 12:04 p.m., the resident reported that his phone was missing from his room and the facility didn't do anything about it. He stated that there are some ladies in the facility that go around and take things from residents' rooms. An interview was conducted on August 6, 2025 at 7:27 a.m. with the Resident Relations Manager (Staff/ #71), who stated that she was responsible for the resident activities program and social services duties. Duties include documenting resident complaints on the grievance form and following up with the resident once the complaint has been investigated. She stated that a missing phone would be reported to the Administrator and residents are usually reimbursed for missing personal property. The resident reported the missing phone and he was going to ask his ex-wife what type of phone he had, so the facility could replace the phone. The phone was not on the inventory list, but she saw him with the phone and she had helped him make phone calls on the phone. During an interview conducted on August 6, 2025 7:57 a.m. with the Administrator (Staff #34), he stated that the facility will replace the phone by the end. During an interview conducted on August 6, 2025 at 12:06 p.m. with the Resident Relations Manager (Staff/ #71), she stated that she has received training on abuse which includes misappropriation of a resident's belongings and if the phone was taken, it is a form of misappropriation. She stated that if there is a possibility of abuse, it must be reported to the Administrator and he reports it to the state agency and completes the investigation. She is aware of residents wandering into other residents' rooms, but doesn't know their names. Staff and the surveyor went to speak with the resident and he stated that he would leave his phone on his tray when he went to therapy. He went to therapy and when he came back, the phone was missing. During an interview conducted on August 7, 2025 at 8:20 a.m. with the Administrator (Staff #34), he stated that he reported the allegation of the missing phone to the state agency yesterday, August 7, 2025, when it was identified as stolen. He stated that the resident had reported the phone missing; the facility searched for the phone and it was not found. He stated that it was possible that the phone was misappropriated, but highly unlikely that it was stolen. He stated that the resident went to one appointment and was transported in a vehicle owned by the facility to and from the appointment. The facility called the place where the resident had the appointment and searched the vehicle, but did not find the phone. He stated that the facility internally investigated and determined that the phone was not stolen. He stated that they did not document any interviews with residents, but talked to a few located around the resident's room and did not document any interviews with staff. He stated that the resident had mentioned some Spanish speaking women (residents) that wander around. The facility policy, Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program states that the facility must identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that medications were administered as prescribed for one resident (#24). The deficient practice could impact the health and wellbeing of the residents. Findings included:Resident (#24) was admitted to the facility on [DATE] with diagnoses that included type II diabetes, acquired absence of unspecified leg below the knee, and chronic kidney disease. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident had a moderate cognitive impairment. The order summary included: -March 25, 2025, Oxycodone-Acetaminophen oral tablet 5-325 mg give one tablet by mouth every four hours as needed for pain scale of 7-10.-April 6, 2025, Insulin Lispro (1 unit Dial) Subcutaneous Solution Pen-injector 100 unit/ml Inject as per sliding scale: if 0-179=0, Notify MD if BS 60 or below, follow hypoglycemic protocol. 180-200=3 units; 201-230=4 units; 231-260=5 units; 261-290=7 units; 291-320=9 units; 321-350=11 units; [PHONE NUMBER]=13 units. Notify MD if BS is 351 and over, document in NN. Follow hyperglycemic protocol, subcutaneously before meals and at bedtimes related to type II diabetes mellitus without complications. The care plan dated March 25, 2025 revealed the resident has a diagnosis for Diabetes Mellitus. Interventions included that the resident is dependent on insulin for management of diabetes. Monitor, document, and report to the physician as needed for serious symptoms (s/sx) of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, and coma. The care plan dated [NAME] 25, 2025 included that the resident is on opiate medication. Interventions included to educate the resident on he potential risks, adverse outcomes, complications, and medication interactions associated with opioid use including death. An interview was conducted on August 6, 2025 at 10:44 a.m. with a registered nurse (RN/staff #50), who stated that an order for insulin should include: the name of the resident, amount, and slide scale parameters. She would check the resident's blood sugar level (BS) and then administer the amount of units based on the sliding scale. She stated giving insulin outside of the scale/range could cause the resident to be hypoglycemic or hyperglycemic. She stated that if the BS is too high, she would contact the physician for further instructions which may include monitoring the resident and even to administer more insulin; the physicians instructions should be documented in the progress notes. She would follow hyperglycemic protocol, which is to check the resident's BS every half hour to an hour to see if the insulin worked. When administering pain medication as needed (PRN), the order should have the dosage and the pain scale parameters and if the parameters are not followed, there is a risk of overmedicating the resident and the physician should be contacted for further instructions. She reviewed the MAR dated July 2025 and stated that the resident's BS was 356 on July 11, 2025 at 8:00 p.m.,13 units of insulin was administered, and the resident's BS was 371 on July 13, 2025 at 11:00 a.m., 13 units of insulin was administered. She stated that the physician should have been notified as per the order and the hypoglycemic protocol should have been followed. She reviewed the progress notes and stated that there was no documentation regarding the physician being notified and then she reviewed the vitals to see if the hypoglycemic protocol was followed and stated that there were no additional BS checks for the resident on July 11, or July 13, 2025. Then she reviewed the MAR dated July 2025 and stated that Oxycodone-Acetaminophen oral tablet 5-325 mg give one tablet by mouth every four hours as needed for pain scale of 7-10 was administered on July 6, 2025 at 12:00 p.m. for a pain level of 0 which was outside the pain parameters. She stated that administering pain medication outside of the parameters could cause an overdose. An interview was conducted on August 6, 2025 at 11:28 a.m. with the Director of Nursing (DON/staff #10), who stated that a physician's order is needed to administer insulin per a sliding scale and the purpose of administering insulin per a sliding scale is so the correct amount of insulin is administered based on the resident's blood sugar level (BS). She stated that if the order included instructions to contact the physician when the BS is above a certain level, it is her expectation that the nurse contact the physician and document the instructions given by the physician in the progress notes. She stated that if the physician is not notified and the resident is not being monitored, there is a risk of the resident becoming more hypoglycemic which could result in a coma. She stated that when the resident's BS is high, it is her expectation that the nurse continue to monitor the resident's BS level. She stated that when pain medications administered as needed (PRN), the nurse should follow the pain scale parameters on the order and if not followed, there is a risk of the resident overdosing. The facility policy, Medication Orders states that medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. It did not include that order must be followed when medications are administered.

Based on observations, staff interviews and record review, the facility failed to provide an ongoing activity program that provided activities to meet the individual interests and needs to enhance the quality of life for one resident (#12). The deficient practice could result in resident isolation and decreased quality of life.Findings included:Resident #12 was admitted to the facility on [DATE]. The diagnosis included pleural effusion, not elsewhere classified, thoracic, difficulty in walking, not elsewhere classified aortic ectasia, chronic obstructive pulmonary disease, unspecified, difficulty in walking, not elsewhere classified, muscle weakness (generalized). The physician orders dated July 16, 2025 revealed that the resident may participate in overall activity plan and exercise program that do not interfere with treatment plan.The admissions activity's assessment dated [DATE] revealed that having books, newspapers, and magazines to read was not very important to the resident. Per the documentation, listening to music and going outside to get fresh air when the weather is good was somewhat important to the resident. The documentation also included that being around animals such as pets, doing favorite activities and participating in religious services or practices were very important to the resident. Activities of interest included arts and crafts, gardening/arranging, and pets. Therapeutic interventions included the need for reading glasses. Holistic interventions for pain, anxiety and behaviors were music.The care plan dated July 25, 2025 included that the resident had previous recreational interests and patterns meeting with friends, time alone, watching TV and potential for altered activity pattern; and, was dependent on staff for activities, cognitive stimulation, social interaction. Interventions included to provide leisure supplies for self-directed pursuits, introduce to other residents with similar interests, disabilities, and/or limitation and offer a variety of activity types and locations; assist with arranging community activities, arrange transportation, assistance with activities of daily living (ADLs) as required during the activity and assistance/escort to activity functions. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status with a score of 12, indicating moderate cognitive impairment. The assessment also included that resident was usually understood with some difficulty communicating some words or finishing thoughts, but was able if prompted or given time; and, required partial to moderate assistance with wheelchair use.Review of the Activities Task tab for the following areas of interest during the 30 day-look back period:Arts and craftsGroup programsMusicSpecial events/parties/socials Spiritual servicesRoom visit Cultural activitiesBingoHowever, the documentation does not indicate whether the resident was offered or participated in any activities, except on August 5, 2025, when they were marked as yes for special events and refused for a room visit.Review of the activity participation progress notes revealed no documentation for resident #12 since admission date of July 16, 2025.An interview was conducted with resident #12 conducted on August 5, 2025 at 11:13 a.m. revealed an activity calendar hanging on the resident's closet door. Resident #12 stated that she did not know what the activity calendar was and did not know anything regarding activities, but would like to attend. Resident #12 stated that no one has come to invite or tell her about the daily activities.In an interview conducted with Resident #12 on August 6, 2025, at 1:25 p.m., the resident stated that staff had not invited her to activities and that she only attended one because she happened to be near the activity room when it started. She said that someone had left her a puzzle book, but she was unable to use it because she did not have her reading glasses. She also said there was a flyer on her cupboard, which she later learned was an activity schedule, but she could not read it without her glasses. Resident #12 further stated that she would appreciate help getting to activities, as she often does not know what was happening; and, she was from another state, does not know anyone locally, and would like to meet more people and participate in more activities if staff would invite her.An interview was conducted on August 6, 2025, at 11:34 a.m. with Certified Nursing Assistant (CNA/Staff #1) who stated that she helps residents participate in activities of their choice by informing them about scheduled events and encouraging them to attend. She said that if a resident has therapy, medications, or ADL (activities of daily living) needs, she ensures their schedule was coordinated so they can still participate in activities. The CNA also said that if she notices a resident refusing activities or showing a change in participation, she reports it to the nurse. She added that activity staff were present daily to meet residents' activity needs.An interview with the Activities Manager (Staff #71) was conducted on August 6, 2025, at 1:34 p.m. The Activities Manager stated that the activity program was run by herself and three activity assistants. She said that the facility holds care plan meetings to identify each resident's needs, interests, cultural background, and preferences, including family input. She said the activities department offers both group and individualized activities, with ideas for new activities gathered through resident council meetings and direct conversations with residents. The Activities Manager stated that resident activity participation-including level of participation, whether activities were offered, and any refusals-was documented in the electronic record. She said that to ensure residents are encouraged or invited to activities, staff were expected to personally visit and invite each resident to activities suited to their interests. During the interview, a review of Resident #12's clinical record was conducted. The Activities Manager said that there was no documentation showing activities were offered or refused for each of the resident's identified areas of interest. She further stated that August 6, 2025, was the first day staff had offered an activity to Resident #12.During an interview with the Administrator (Staff #34) on August 6, 2025, at 2:16 p.m., the Administrator stated that his expectations for the activity program and staff were to ensure that residents are asked about the activities they want to participate in, their likes, and cultural preferences. He said that staff should be inviting residents to activities, posting schedules so residents are aware of what is being offered, and most importantly, personally inviting them-even if they refuse. The Administrator stated that failing to do so could result in resident isolation.Review of the facility policy titled Personal Care: Activity Evaluation revealed that in order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities. An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident. The activity evaluation is used to develop an individual activities care plan (separate from or as part of the comprehensive care plan) that will allow the resident to participate in activities of his/her choice and interest. Each resident's activities care plan relates to his/her comprehensive assessment and reflects his/her individual needs

Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#56) was afforded privacy during a medical consultation. The deficient practice could result in residents' rights to privacy not being respected. Findings included: Resident (#56) was admitted to the facility on [DATE] with diagnoses that included heart failure, hyperlipidemia, and a hip fracture. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident was cognitively intact. A psych note completed on August 5, 2025 at 12:15 p.m. revealed an encounter was conducted and completed with the patient's/guardian's consent over telemedicine, including both audio and video components due to the client being located in a different location than the provider. Patient location: Address of record, Facility. The patient was sitting in wheelchair in her room. She reported feeling better than last visit, less shortness of breath, and has been happy lately. She stated she is sleeping and eating well and denied any concerns. The resident had a brief interview for mental status score (BIMS) of 12 dated July 21, 2025. On August 5, 2025 at 11:27 a.m. a behavior health technician (staff #10 ) was observed entering resident #24's room without knocking or asking if she could enter. Staff #106 began conducting a telemedicine with resident #24, while the surveyor was interviewing resident #24's roommate. The doctor was asking the resident questions about her health and staff #106 was repeating the questions loudly because the resident was hard of hearing. Staff #106 was loud enough for the roommate and surveryor to hear what was being discussed and the residents answers could also be heard. Doctor wanted to know if the resident was feeling okay because she was feeling well before. The surveyor exited the room and waited for the consultation to be completed, so the resident could complete the consultation in private and waited to interview staff #106. When attempting to interview staff #106 she was asked her name and she stated that it didn't matter because she doesn't work for the facility and left. On August 5, 2025 11:30 a.m., a therapy technician (staff #112) was observed entering resident #24's room without knocking or asking if she could enter. She asked if the resident was ready for therapy. An interview was conducted on August 7, 2025 9:28 a.m. with a certified nursing assistant (CNA/staff #31), who stated that she has received training on resident rights which includes the right to privacy. She stated that she needs to knock, greet the resident, indentify herself, and explain what procedure she is going to provide for the resident. If there was a roommate, and she was going to discuss something, she would talk in low voice to ensure the resident's privacy. If she was going to provide care, she would shut the door and pull the curtain to maintain privacy. An interview was conducted on August 7, 2025 at 12:25 p.m. with the Director of Nursing (DON/staff # ), who stated that all staff receive training on resident rights, which includes the right to privacy. Staff are trained to knock on the resident's bedroom door, introduce his or herself and wait for the resident to respond. She also stated that in order to maintain privacy, it is her expectation that staff that telemedicine be conducted in a private area. The facility policy, Resident Rights/Dignity: Resident Rights Guidelines for All Nursing Procedures states that for any procedure that involves direct resident care, follow these steps: knock and gain permission before entering the resident's room. Introduce yourself to the resident if he/she is unfamiliar with you, or if he/she may not recognize you due to memory loss. If visitors are present, ask them to wait outside unless the resident requests that they remain in the room.

Based on interviews, review of clinical record, and review of facility policy, the facility failed to ensure a physician order was followed for one resident (#1) regarding a laboratory order. The deficient practice could lead to diagnostic testing not being completed and a missed diagnosis.Findings include:Resident #1 was re-admitted to the facility December 30, 2023, with diagnoses that included pneumonitis due to inhalation of food, acute respiratory failure, type 2 diabetes mellitus with diabetic neuropathy, repeated falls, adult failure to thrive, personal history of sudden cardiac arrest, anxiety disorder, major depressive disorder, cannabis use in remission, contracture of muscle, paranoid schizophrenia, and bipolar disorder.A quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Section E revealed the resident had no behavioral symptoms exhibited.A physician order dated April 9, 2025, indicated for a urinalysis reflex test and toxicology screen, and that the toxicology screen could be completed in-house (at the facility).A Health Status Note dated April 9, 2025, revealed the nurse noted the resident was talking slowly, and had pale-looking skin. Suddenly, the resident started laughing and acting out of the normal. The nurse noted that he was not behaving as usual. The nurse notified the physician, and the physician ordered a urinalysis with a toxicology screen.A review of the Medication and Treatment Administration Record (MAR/TAR) for April 2025 revealed the order for the urinalysis reflex test and toxicology screen was left blank, with no evidence that it was completed.Review of the clinical record revealed no evidence that the urinalysis reflex test and toxicology screen were completed and no evidence of any results and no evidence of any communication regarding the order.An interview was conducted with the Medical Records Manager (Staff #47) on August 6, 2025, at 8:49 a.m. Staff #47 stated that the facility utilizes a mobile laboratory company for laboratory orders and that the results are automatically uploaded in the electronic medical record. Staff #47 reviewed the clinical record for Resident #1 and stated that she could not locate any urinalysis results for April 2025.An interview was conducted with a Registered Nurse (RN / Staff #63) on August 6, 2025, at 9:02 a.m. Staff #63 stated that if there is an order for a urinalysis, then the nurse would schedule the laboratory order, and the mobile laboratory company completes the order and automatically uploads the results in the resident's electronic medical record. Staff #63 reviewed Resident #1's clinical record and stated that he could not locate the resident's urinalysis results from April 2025.An interview was conducted with the Director of Nursing (DON / Staff #10) on August 6, 2025, at 9:18 a.m. The DON reviewed the MAR/TAR for April 2025 and stated that the urinalysis and toxicology screen order was not marked as completed. The DON stated that she would reach out to the mobile laboratory company to see if there were any results from that date.An additional interview was conducted with the DON on August 6, 2025, at 10:28 a.m. The DON stated that she talked to the nurse who completed the toxicology screen in-house for Resident #1, but that the nurse did not document its completion or the results. Additionally, the DON stated that the nurse did not read the whole order and that the urinalysis was not collected, so there was no documentation of it.A follow-up interview was conducted with the DON on August 7, 2025, at 11:31 a.m. The DON stated that her expectation is that staff should follow physician orders. The DON stated that if a lab or test is ordered by a physician and not completed by staff, then the risk to a resident could be that an infection could be missed or abnormal lab results not caught by the clinical team. Regarding the missed urinalysis laboratory order for Resident #1, the DON stated that it would not meet her expectation, and that staff should have asked the physician for a repeat order for collecting the urinalysis and that the results of the toxicology screen should have been documented in the medical record to help subsequent clinical team members track to make sure things are done.Review of the facility policy titled Medication Orders, revised November 2014, revealed that each resident must be under the care of a Licensed Physician authorized to practice medicine in this state, and that a current list of orders must be maintained in the clinical record of each resident.Review of the facility policy titled Charting and Documentation, revised April 2008, revealed that all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum the date and time the procedure/treatment was provided, the assessment data and/or any unusual findings obtained during the procedure/treatment, and the name and title of the individual(s) who provided the care.

Based on observation, interviews, clinical record review, and review of facility policy and procedure, the facility failed to ensure speech therapy services were provided for one resident (#8) when indicated. The deficient practice could lead to residents not receiving rehabilitative services when indicated to assist in reaching their highest practicable level of function. Findings include:Resident #8 was originally admitted to the facility August 2, 2016, and re-admitted to the facility April 16, 2023, with diagnoses that included adjustment disorder with mixed anxiety and depressed mood, aphasia following cerebral infarction, functional dyspepsia, dysphagia, contracture of muscle in multiple sites, epilepsy, and cerebral infarction.A care plan dated December 17, 2019, revealed that Resident #8 has a communication problem due to stroke and unable to form words, and that the resident uses sounds, gestures, and inflection of tone to communicate. Interventions included for staff to anticipate and meet the resident's needs, and to monitor, document, and report to the physician changes in Resident #8's ability to communicate and potential for improvement.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #8 had a brief interview for mental status (BIMS) assessment that was not attempted, as the resident was rarely or never understood. A Quarterly Nursing Summary Note dated November 27, 2023, revealed Resident #8 was rarely/never understood when expressing ideas and wants, and that the resident had aphasia and used sounds or jesters for communicating.A Therapy Services Screen dated January 16, 2024, and signed by a Speech Language Pathologist (SLP / Staff #91), revealed a speech therapy evaluation was recommended due to Resident #8's poor speech intelligibility post cerebrovascular accident (CVA / stroke), and that the resident's family had requested speech therapy services. The screen revealed that speech therapy indicators for Resident #8 included impaired ability to verbalize simple and complex ideas, and impaired intelligibility. Additionally, the screen revealed that the resident was observed, and a speech therapy evaluation was recommended. Despite the recommendation for a speech therapy evaluation, the clinical record was reviewed and revealed no evidence of communication of the recommendation to the physician or the clinical team, and no evidence of any speech therapy orders at that time, and no evidence that speech therapy services were provided then.Another Quarterly Nursing Summary note dated March 7, 2024, revealed the resident was oriented x 3, and unable to form sentences and words. Additionally, the resident was rarely/never understood when expressing ideas and wants.An additional quarterly MDS assessment dated [DATE], revealed that a BIMS assessment was not attempted, as the resident was rarely or never understood.An observation was conducted on August 6, 2025, at 11:12 a.m. of Resident #8 in his room. Resident #8 was sitting in his wheelchair. An interview was attempted at that time, however, the resident was unable to form phrases or sentences to communicate.An interview was conducted on August 6, 2025, at 12:00 p.m. with the Director of Rehabilitation (DOR / Staff #86), who stated that the therapy department conducts therapy screens to determine if a resident may need therapy services, or the nursing staff will communicate with the therapy department to alert therapy staff if a resident may need therapy services. The DOR stated that then, an authorization (auth) request is placed with the resident's insurance to determine the resident's insurance coverage for therapy visits. The DOR reviewed the clinical record for Resident #8 and stated that Resident #8 had a therapy screen completed on January 16, 2024, and that it was recommended that he be evaluated by speech therapy. The DOR stated that no speech therapy evaluation was completed in 2024. The DOR also stated that the record revealed no therapy screens were conducted for the year 2025, and that the resident had no therapy evaluations completed in 2025.An interview was conducted with the Director of Nursing (DON / Staff #10) on August 6, 2025, at 12:22 p.m. The DON stated that for long term care residents, that if staff notice a change in a resident, or if the resident or their family requests therapy services, then the resident would be referred to the therapy department and screening is completed. The DON stated that then the facility staff determines if the resident can be approved by insurance for therapy services.A formal request was submitted to the facility on August 6, 2025, at 12:40 p.m. for any insurance auth requests for Resident #8 for 2024-2025, and additionally, for any speech therapy evaluations and treatment notes for 2024-2025.The facility provided a signed statement dated August 6, 2025, that there were no insurance auth requests and no speech therapy notes completed for Resident #8 for the requested timeframe.An interview was conducted on August 6, 2025, at 2:07 p.m. with a Licensed Practical Nurse and Care Coordinator (LPN / Staff #17), who stated that there were no insurance auth requests submitted in January 2024 for Resident #8, and that there were no physician orders for speech therapy for that timeframe.An interview was conducted with the Business Office Manager (Staff #35) on August 7, 2025, at 8:26 a.m. Staff #35 stated that if a resident is recommended for therapy and requires insurance authorization for visit coverage, then the therapy department staff will bring a form to Staff #35, and that Staff #35 verifies the insurance plan for the resident. Then, Staff #17 is in charge of requesting insurance authorization from the insurance.An interview was conducted with the Director of Nursing (DON) on August 7, 2025, at 11:31 a.m. The DON stated that Resident #8 had a history of a stroke and that he had speech impairments. The DON stated that Resident #8 is able to state yes and no, and is able to make noises, and point and make gestures, however Resident #8 could not form phrases or sentences to communicate. The DON stated that her expectation if a resident or family member requests therapy services, and a licensed clinician screens that resident and identifies the need for further evaluation from a speech therapist, that the staff should follow physician orders and provide the recommended rehab services. The DON stated that in the case of Resident#8, that the previous speech therapist (Staff #91) had screened the resident in January 2024 and had failed to communicate the recommendation for speech therapy to the physician or the rest of the clinical team, and that is why there was no physician order for speech therapy and no insurance auth request or subsequent therapy visits. The DON stated that if the clinical team had received the communication regarding the recommendation for speech therapy for Resident #8, then the staff would have obtained physician orders and requested auth from the insurance. The DON stated that this was the first time the clinical team had seen the speech therapy screen note. The DON stated that fortunately, Resident #8 had not shown a functional decline, but additionally, that the DON would expect a trial of therapy, when recommended, to determine if that resident could achieve a better level of function.Review of the facility policy titled Rehabilitative / Restorative Care: Functional Impairment - Clinical Protocol, effective January 1, 202, revealed that upon admission to the facility, whenever a significant change of condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident's function along with their physical condition. The staff and physician will identify individuals with potential for significant improvement in function or significant decline in function, including the ability to perform activities of daily living (ADLs). The staff and physician will collaborate to identify a rehabilitative or restorative care plan to help improve function and quality of life and meet a resident's goals and needs and attain other desired outcomes such as discharge to the community.Review of the facility policy titled Rehabilitative / Restorative Care: Speech Therapy, effective January 1, 2024, revealed that the purpose of the procedure is to identify, assess and treat speech and language problems, including swallowing disorders. Preparation included to review the resident's care plan to assess for any special needs of the resident. Speech therapists treat stroke survivors and other brain injury survivors who experience impaired ability to swallow or have difficulty expressing thought or understanding language. These residents may experience aphasia. Expressive aphasia is a problem with what to say. Receptive aphasia is a problem with understanding what has been said. The speech therapist works with other rehabilitation and medical professionals and families to provide a comprehensive evaluation and treatment plan for residents with any of the problems in speech listed above.Review of the facility policy titled Rehabilitative / Restorative Care: Scheduling Therapy Services, effective January 1, 2024, revealed the therapist shall interview the resident and consult with the attending physician as to the type of treatment to be administered.

Based on interviews, clinical record review, and facility policy, the facility failed to ensure that one resident (#12) had an order for oxygen prior to administration. The deficient practice could result in resident receiving oxygen without a physician order. Findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses that included dementia and dependence on supplemental oxygen. Review of physician orders revealed an order for 0.5 to 5 liters (L) of oxygen, as needed, dated May 24, 2023 and discontinued on September 1, 2023. Review of a progress note dated September 7 - 9, 2023 revealed resident was on 2 L oxygen via nasal cannula. Review of a progress notes dated December 4 - 5, 2023 revealed resident was on 2 L oxygen via nasal cannula. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) could not be completed due to the resident being rarely or never understood. The MDS also showed that the resident was not on oxygen therapy. Review of vitals including oxygen saturation starting June 16, 2024 revealed resident was on a nasal cannula. An observation was conducted on July 22, 2024, resident #12 was observed with 2 L of oxygen via nasal cannula. The registered nurse (RN/staff #83) was observed going into the resident #12's room to replace the resident's nasal cannula. An interview was conducted with the RN (staff #83) and she reviewed the electronic record for resident #12, and confirmed there was no order for oxygen. The RN stated that she recalled family wanted resident on comfort cares only, including no oxygen. The RN said she removed the nasal cannula and put it back on after seeing tha the resident needed the oxygen. The RN said that the resident's family was made aware and they were okay with the change, but the order was not renewed. The RN said the resident was on 2 L oxygen prior to comfort care measures, so that's what theRN had the resident on and it was as needed only. Review of a progress note dated July 22, 2024 revealed physician was contacted and [NAME] order was received to renew as needed oxygen order per resident comfort care needs. It noted that the orders were updated and that staff will continue to monitor every shift to ensure oxygen requirements were met. An interview was conducted on July 25, 2024 at 8:21 AM with the Director of Nursing (DON) who stated that her expectation was that a an order was required before administering a medication, and that oxygen was considered a medication. The DON stated that it was up to the physician how many liters of oxygen the resident would received. The DON reviewed resident #12's chart and confirmed that there had not been an order for oxygen since September of 2023. The DON said that this did not meet expectations. Review of a policy titled, Orders/Receiving/Transcribing: Medication Orders updated on January 1, 2024, revealed that when recording orders for oxygen, specify the rate of flow, route, and rationale. Review of a policy titled, Respiratory/Pulmonary conditions: oxygen administration, updated January 1, 2024 revealed staff must verify that there is a physician order for oxygen administration. In addition, it noted that before administering oxygen and while the resident is receiving oxygen therapy, assess for the following: signs or symptoms of cyanosis, hypoxia, oxygen toxicity, vital signs, lung sounds, arterial blood gases and oxygen saturation, and other lab results.

Based on clinical record review, facility documentation, interviews, and facility policy, the facility failed to ensure one resident (#23) and/or their representative was informed of the risks and benefits of the flu vaccine, prior to administration. The deficient practice can result in the resident and/or the resident representative not being aware of the benefits and the potential adverse side effects of receiving a vaccination. Findings include: Resident #23 was admitted to the facility on [DATE] with diagnoses that included cerebral infraction due to embolism, dysphagia, type 2 diabetes mellitus and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 8 indicating the resident's cognition was moderately impaired. Review of records revealed resident #23 had a family member designated as his responsible party, substitute decision maker. Review of records titled, Clinical-Immunizations revealed influenza immunization was administered to resident #23 on November 3, 2023. Review of an immunization record revealed there was no consent for the influenza vaccine for 2023. Review of a progress note dated November 3, 2023 revealed resident received flu shot on L. (left) deltoid. An interview was conducted on July 24, 2024 at 9:29 am with registered nurse (RN/staff #82). The RN stated that during admission staff goes over flu, pneumonia, and covid vaccines with the residents and determine whether they have been vaccinated or not and if not, did they want to. The RN stated that if residents wanted to be vaccinated, the consent form was given to the resident and staff would explain the signs and symptoms of receiving vaccines. Further, the RN said that once they received the consent for the vaccines, staff uploads it in the electronic record and an order for the vaccine was placed in the system. The RN stated that once the vaccine becomes available from pharmacy, staff administered the vaccine, document it and a seventy two-hour post vaccine monitoring was completed. In addition, the RN stated that before administering a vaccine, she would verify that a consent was signed, check the order, and then administer the vaccine. She added that the vaccine consent was in the residents electronic health record. The RN stated that the vaccine consents were part of the admission process, and were uploaded in the residents electronic health record. The RN further stated that consent for the flu vaccine was done every year. An interview was conducted on July 24, 2024 at 1:20 pm with the medical records manager (MRM, staff #44). The MRM stated that she scans documents such as laboratory results, imaging documents, progress notes, and all admission hospital paperwork. The MRM stated that consents in paper form were scanned manually every morning. She added, that if they were received later on the day, it would be scanned the following day. The MRM stated that for most part, the scanning of paperwork gets done by the next day. An interview was conducted on July 24, 2024 at 3:35 pm with the director of nursing (DON/staff #34). The DON stated that admission paperwork/packet included the advance directive, vaccine consent, and inventory paperwork for belongings. The DON stated that once the admissions paper work were completed, they were submitted to the medical records to make sure they were scanned into the resident's electronic records. The DON stated that for vaccine consent, if the patient had not had the vaccine such as the flu or pneumonia vaccine, they would get an order from the doctor, send it to pharmacy, and when they receive the vaccine, they will administer the vaccine to the resident. The DON reviewed resident #23's records and stated that resident received immunization on November 3, 2023 and that she was not able to find a consent for the 2023 flu vaccine. The DON stated that she would verify with medical record about the consent for the 2023 flu vaccine. An interview was conducted on July 25, 2024 at 10:55 am with RN (staff #61). The RN stated that before administration of the flu vaccine, she checks for allergies and consents, then she prepares the vaccine and then gives the flu shot. The RN stated that if she did not see a consent, she would ask the resident or their power of attorney (POA). And, the RN stated that if the resident could not sign the consent, she would ask the POA. The RN stated that if the POA signed the consent, then she would administer the vaccine shot. The RN stated that if a verbal consent was received from a POA or residents, then two nurses would sign the consent. The RN also stated that after receiving verbal consent from the POA, she would chart it in the progress note stating that she called the POA and received a verbal consent and witnessed by another nurse. Further review of resident #23's medical records revealed no flu vaccine consent for 2023. Review of facility's policy titled, Resident Rights/Dignity: Requesting, Refusing and/or Discontinuing Care or Treatment, effective date January 1, 2024 revealed (1) Residents/representative are informed (in advance) of: a. the care that will be furnished or made available to the resident based on his or her assessment and plan of care; b. the risk and benefits of the proposed care; (2) Residents/representatives are informed of his or her rights to: a. request, refuse and/or discontinue treatment. Review of facility's policy titled, D023-Infection Control: Vaccination of Residents, effective January 1, 2024 revealed 1. prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. 2. Provision of such education shall be documented in the resident's medical record.

Based on facility documents and staff interviews and review of facility policy and procedure, the facility failed to ensure that the Daily Staff Postings for nursing staff was accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information. The facility census was 49 residents and the sample was 13. Findings include: A review of four randomly chosen days of staff postings compared with the actual hours worked by staff on those days revealed that none of the staff postings matched the actual hours worked by staff. Review of January 6, 2033 staff posting indicated: - RN Night shift: 1 RN (Registered Nurse) worked 4 hours on the night shift. However, review of the punch detail revealed that 1 RN worked 1.5 actual hours on the night shift. Review of January 7, 2023 staff posting indicated: -RN Day shift: 1 RN worked 12 hours. However, the review of the punch detail revealed that 2 RN's worked 19.98 actual hours. -Day shift: 1 LPN worked 12 hours. However, the punch detail revealed that 2 LPNs worked a total of 14 actual hours. -CNA Night shift: 3 CNAs on the night shift. However, the punch detail revealed that 1 CNA worked a total of 8 actual hours. Review of January 8, 2023 staff posting indicated: -LPN Night Shift: 1 LPN worked 4 hours, however the punch detail revealed that 1 LPN worked a total of 7.55 actual hours -CNA day shift: 7 CNA day shift worked 52.5 hours. However, review of the punch detail revealed 6 CNA worked with a total of 44.14 actual hours. -CNA Evening Shift: 5 CNA worked 37.5 hours. However, review of the punch detail revealed that 5 CNAs worked a total of 35.28 actual hours. Review of January 9, 2023 staff posting indicated: -CNA Day Shift: 6 CNAs worked 45 hours. However, review of the punch detail revealed that 7 CNAs worked a total of 46.72 actual hours. -CNA Evening Shift: 5 CNA worked 37.5 hours. However, 5 CNAs worked a total of 35.28 actual hours. An interview was conducted on January 26, 2023 at 9:43 AM with a Registered Nurse (RN/staff #24), who reviewed the staff postings and actual hours worked for licensed and unlicensed nursing staff on January 6, 2023 through January 9, 2023. She stated that the Daily Staff Postings were not accurate for those dates. An interview was conducted on January 26, 2023 at 11:32 AM with the Director of Nursing (DON/staff #79), who stated that she expected the Daily Staff Posting to be accurate for the number of staff and the actual hours worked. She also stated that the Staff Postings are completed by the night nurse, and she expected that they would be updated. She further stated that the risk of not having accurate Staff Postings could result in residents and their families not receiving current information.

Based on clinical review, staff interviews, facility documentation and policy review, the facility failed to ensure that allegations of abuse for two residents (#18 and #13) were reported immediately to the Administrator and to the state agency within the required time frame. The facility census was 49 residents and the sample was 13. The deficient practice could result in abuse allegations not being reported. Findings include: Resident #18, was admitted on [DATE] with diagnoses that included type 2 diabetes, asthma, chronic obstructive pulmonary disease, pain, systemic lupus erythematosus, major depressive disorder, morbid obesity, and muscle weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment further revealed a Mood Severity Scale of 06, which indicated mild depression, with no behaviors exhibited. The facility investigative report submitted to the State Agency on July 28, 2022 revealed that resident #18 had a verbal altercation with a fell ow resident's family member, and the family member struck her on the head. The incident happened on July 24, 2022 at around 3:00 PM. It had previously been reported that the resident had a heated conversation with the fell ow resident's family member, after which staff decided to move the resident to another room and decided to prohibit the daughter of the other resident from unsupervised visits. No prior report had mentioned physical contact of any sort. The investigative report included that the incident was reported to the police, APS (Adult Protective Services), Ombudsman and the State Agency (SA) on July 28, 2022. However, per the documentation, the incident occurred on July 24, 2022, but was not reported to the SA and APS until July 28, 2022 (four days after the incident). Review of the clinical record revealed no evidence of the incident that occurred on July 24, 2022 in progress notes or event notes. An interview was conducted on January 24, 2023 at 1:19 PM with a Licensed Practical Nurse (LPN/staff #40), who stated that she was the nurse on the floor and observed the altercation. She stated that she stepped in and asked what was happening, and asked the roommate's daughter to stop and move further down the hallway. The LPN stated that she talked to the resident who stated that she was hit on the head by the family member at the time the incident occurred. The LPN stated that she did not see the visitor hit the resident at the time the incident occurred. She further stated that she reported the altercation to the Director of Nursing (DON) at that time via telephone. The Nurse also stated that it would be abuse for a visitor to yell at a resident, and should be reported immediately. She further stated that it was the facility policy to document any resident altercations in the clinical record. She reviewed the clinical record and stated that she did not document the occurrence in the clinical record. An interview was conducted on January 24, 2023 with a Certified Nursing Assistant (CNA/staff #34), who stated that a visitor yelling at a resident would be considered abuse and should be reported immediately. An interview was conducted with the resident on January 24, 2023 at 2:01 PM, who stated that her roommate's daughter yelled/cursed at her, then hit her on the head with her knuckle. She also stated that she told the nurse about it later, and told the ladies in activities the next day and they reported it to the Administrator. An interview was conducted on January 24, 2023 at 2:26 PM with the Activities Manager (staff #3), who stated that the resident stated that that she had a disagreement with her roommate's family member. She also stated that she could not remember that the resident told her she was hit on the head, but that she had reported it to the Administrator. An interview was conducted on January 24, 2023 at 2:55 PM via telephone and a translator, with the facility [NAME]/transport (staff #63), who stated that she observed the incident between the visitor and resident #18. She stated that it occurred at the nursing station, that the visitor was yelling at the resident. She also stated that she did not see any signs of violence, or that the resident had been hit. She further stated that after the incident the nurse had a conversation with both the resident and the visitor. The [NAME] stated that the visitor yelled at the nurse that she wanted her mother's room changed. An interview was conducted on January 26, 2023 at 10:57 AM with the DON (staff #79), who stated that any allegation of abuse or suspected abuse, should be reported to the charge nurse who would notify the Executive Director (ED) and DON. She stated that an investigation would be started immediately. The DON stated that at first they would make sure the resident is safe, then start the investigation process. She also stated that the ED is the designated abuse reporter for the facility, and would start an investigation as soon as he was notified. The DON stated that a reportable abuse incident would include a threat to a resident, verbal abuse, physical contact, theft, loss, injury of unknown origin, or a fall with major injury. She stated that if someone was yelling at a resident it would be considered verbal abuse. She also stated that if a visitor was yelling or confronting a resident, she would consider that as putting the resident in jeopardy and should be reported as abuse. She stated that if a resident alleges that someone hit them, then they would start an investigation immediately. She stated that the incident occurred on a weekend, that involved a nurse hearing a visitor speaking to the resident in a loud voice. The DON also stated that when a resident reports being struck by a visitor, staff or another resident, the DON and ED should be immediately notified and an investigation would be initiated. An interview was conducted on January 26, 2023 at 12:31 PM with the Clinical Compliance Director (staff #86), who stated that he was the Director of Nursing at the time of the incident. He stated that he had been notified of the incident but was not told that the visitor was yelling at the resident, or that the resident was struck. He also stated that the abuse investigation was started four days after the incident occurred after the resident told activities staff that she had been struck. He further stated that the abuse was unsubstantiated through witness interviews who were present at the time it occurred. An interview was conducted on January 26, 2023 at 12:31 PM with the Executive Director (ED/staff #87), who stated that if a visitor is yelling at a resident it would be considered abuse, and would be reportable. He also stated that it should be reported within 2 hours to the SA. The ED further stated that the incident was not reported to the SA on July 24, 2022, because the nurse reported that she had observed a heated conversation, not yelling. He further stated that the resident did not report being hit until July 28, 2023 to a Case Manager, not an Activity staff member Further interview was conducted with LPN (staff #40) on January 26, 2023 at 12:52 PM. The LPN had initially stated that the resident told her at the time of the incident that the visitor hit her on the head. Later, during an interview with the acting Administrator (on January 26, 2023 at 12:31 PM), she was called into the room and recanted the statement, stating that she misunderstood the question, and that the resident stated that she was struck a couple of days later. Review of the facility policy titled, Abuse Policy, it revealed that abuse is the infliction of injury, that also includes verbal, physical abuse. If abuse is witnessed or suspected, the resident's safety will immediately be secured, and prompt reporting and investigation will be utilized. If abuse is witnessed or suspected, reporting and investigation will take place that includes notification of the ED, who will begin an investigation immediately. The resident suspected of being abused will be monitored and placed on alert charting. If the abuser is a visitor, they will be reported to local law enforcement agency. Review of the facility policy titled, Investigation and Reporting Accidents/Incidents, that included the nurse supervisor/charge nurse or supervisor shall promptly initiate and document investigation of the accident or incident. A Report of Incident/Accident should be submitted to the Director of Nursing Services within 24 hours of the incident or accident. Review of the facility policy titled, Charting and Documentation, should include that all services provided to the resident, or any changes should be documented in the resident's medical record. All incidents, accidents, or changes in the resident's condition must be recorded. 46606 -Regarding Resident #13 Resident #13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified right bundle-branch block, contracture of muscle (right ankle, foot and hand), hemiplegia and hemiparesis following cerebral infarction affect right non-dominant side, mononeuropathy, aphasia, morbid obesity, and dysphagia. Review of the clinical record revealed that the resident sustained a fall with major injury that resulted in a fractured right knee on December 6, 2022. An IDT (Interdisciplinary Team) Fall Review progress note dated December 6, 2022 revealed that the resident suffered a fall with major injury when she attempted to grab things from her closet without asking for assistance or using her call light. Resident #13 was unable to safely complete the task and fell to the floor. During the post fall monitoring the resident exhibited signs/symptoms of pain and swelling to the right knee. The physician and POA (Power of Attorney) were contacted and an order for x-ray was obtained. The x-ray revealed signs of fracture and surgical history. However, it was unclear if the fracture line was from a previous injury or new. Interventions placed post-fall included head to toe assessment and neuro checks. Further review of the clinical record revealed no evidence that the facility reported the incident to the State Agency. Additionally, the IDT Fall Review & Report dated December 6, 2022 (signed December 9, 2022 by the Director of Nursing) indicated that the fall was not reported to the State Agency. In an interview with a Certified Nursing Assistant (CNA/staff #66) conducted on January 26, 2023 at 9:00 am, staff #66 stated that when a fall occurs, the nurse is notified immediately. She said that the resident is assessed with the nurse. Floor mats are placed. There are residents that get up on their own following a fall. Vitals are taken every 15 minutes, 30 minutes, an hour, 4 hours, then 8 hours following the fall. The injury is taken care of or the resident is sent to the hospital if needed. Staff #66 noted that when it comes to reporting falls, unwitnessed falls are reported to the nurse. It is then up to the nurse to further report the incident. An interview was conducted with a Registered Nurse (RN/staff #17) on January 26, 2023 at 10:27 a.m. Staff #17 stated that the process following a fall is that for a witnessed fall, someone can determine if the resident hit their head and confirm the need for neuro check. If unwitnessed, then neuro checks are conducted. The resident is then assessed head to toe for injury and treated as needed. Fall incidents are reported and the physician, POA or responsible party, DON, Case Manager, and Executive Director are all notified. The DON does the review of facts and based on that, it is determined whether it is abuse or neglect related and what additional reporting steps need to be completed. The Director of Nursing (DON/staff #79) was interviewed on January 26, 2023 at 1:31 p.m. Staff #79 stated that for unwitnessed falls, the procedure is that the attending staff immediately notify the nurse. The nurse then begins a head to toe and safety assessment. If the resident is alert and oriented, then they are interviewed regarding the incident. Neuro checks are conducted on the resident. The nurse then notifies the physician and POA and gets treatment orders. Monitoring is conducted for 72 hours. The DON stated that they do not report fall to the State Agency unless there is a suspected abuse or injury. She noted that in the case of resident #13, although she had a major injury, during the IDT and compliance review, it could not be determined whether the injury was old or new. Initially, it was not known the same day. However, after she had pain, she was sent to get x-rays and the fracture was noted. It was unclear if the injury was new or from a previous injury. The resident was referred to Ortho for follow-up. The IDT review determined the fall was not abuse related. Review of a facility policy titled Accidents and Incidents- Investigating and Reporting revised February 2014 indicated that the Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident and submit the original to the Director of Nursing services within 24 hours of the incident or accident. The policy further noted that the Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident An undated facility policy titled Fall Prevention Program indicated that scenarios such as (a) any change in level with or without injury, (b) an episode where resident loses balance and would have fallen without intervention, and (c) when a resident is found on the floor, it is assumed that a fall has occurred-are all considered falls. Furthermore, if injury results from either of these scenarios, an incident report must be filled out for the injury. Investigation guidelines indicated that witnesses and the resident be interviewed regarding the circumstances of the fall, determine potential causes, and note additional pertinent information.

Based on record review, staff and resident interviews and policy and procedure, the facility failed to ensure one resident's right to refuse transfer to another room in the facility. The facility census was 49 residents and the sample was 13. The deficient practice could result in residents not being able to exercise their rights. Findings include: Resident #18, was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, asthma, chronic obstructive pulmonary disease, pain, systemic lupus erythematosus, major depressive disorder, morbid obesity, and muscle weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment further revealed a Mood severity scale of 06, which indicated mild depression, and no behaviors exhibited. Review of the clinical record revealed that the resident was transferred to another room in the facility on July 24, 2022. Review of the clinical record revealed no evidence of a room transfer form, including the resident's signature of agreement. Further review of the clinical record revealed no evidence of documentation that the resident was informed of the room transfer, or verbalized agreement. An interview was conducted on January 24, 2023 at 1:19 PM with a Licensed Practical Nurse (LPN/staff #40), who stated that the resident needs to be notified prior to a room transfer, and a progress note should be completed regarding the notification, and the resident's consent. She reviewed the clinical record and stated there was no documentation in the clinical record regarding the reason for the room transfer, or the resident's agreement. An interview was conducted on January 24, 2023 at 2:01 PM with Resident #18 through an interpreter, who stated that the staff had her change rooms on the day she had an altercation with another resident, but that she did not want to. She also stated that she told staff that she did not want to change rooms. An interview conducted on January 26, 2023 at 11:20 AM with the Director of Nursing (DON/staff #79), who stated that her expectation would be that the resident would be notified regarding a room change, and if they object they would try to accommodate the resident's choices and needs. She also started that the process of a room change would include clinical documentation regarding the need for the room change. She reviewed the clinical record and stated that she did not see any evidence in the clinical record regarding the need for the room change. Review of the facility policy titled, Room to Room Transfer, revealed that the resident should be consulted about the room transfer. The resident's request will be given consideration in making the transfer. The resident should be informed of the room location, the roommate and why the transfer is necessary. Documentation that should be included in the clinical record include: -The date and time the room transfer was made. -How the resident tolerated the move. -If the resident refused the move, the reason(s) why and the intervention taken. The policy also included to notify the supervisor if the resident refuses to move.

Based on clinical record review, staff interviews, the Resident Assessment Instrument (RAI) manual, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments for two residents (#59 and #159) were accurate. The sample size was 16. The deficient practice could result in inaccurate discharge tracking information and data that is not accurate for quality monitoring. Findings include: -Resident #59 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a physician order dated August 13, 2021 that the resident may be discharged home on August 13, 2021. A Health Status Note dated August 13, 2021 included the resident was discharged on [DATE] at 3:00 PM via wheelchair and was transported by spouse in personal vehicle. A discharge summary dated August 13, 2021 revealed the resident was discharged to the community. However, review of the discharge MDS assessment dated [DATE] revealed the resident was discharged to an acute hospital. During an interview conducted on November 3, 2021 at 11:16 AM with the MDS Coordinator (staff #71), she reviewed the discharge MDS assessment for resident #59 and stated that the resident was discharged to the community and not the hospital. Staff #71 stated that she coded the discharge location incorrectly and that she will immediately correct the error. An interview conducted on November 3, 2021 at 11:26 AM with the Director of Nursing (DON/staff #65). After review of the discharge MDS assessment for resident #59, the DON stated that the correction will be completed immediately. The RAI manual instructs to review the clinical record including the discharge orders for documentation of discharge location and code the corresponding 2-digit code. -Resident #159 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing Health Status Note dated October 23, 2021 revealed the resident arrived at 5:50 PM. The note included the resident had an open area to the left heel and to the gluteal cleft. The care plan revealed the resident had a stage 2 pressure ulcer to the sacrum and an unstageable pressure ulcer to the left heel (October 23, 2021) with the goal that the pressure ulcer will show signs of healing and remain free from infection. Review of the clinical record revealed physician orders dated October 27, 2021 to cleanse and pat dry the stage 2 pressure ulcer to the sacrum, apply thin layer of [MEDICATION(S)] and cover with foam dressing every day; and to cleanse and pat dry the unstageable pressure ulcer to the left heel, apply thin layer of [MEDICATION(S)] and cover with foam dressing, secure with gauze roll every day. A physician order dated October 28, 2021 included to send the resident to the emergency department (ED) for evaluation and treatment. A health status note dated October 28, 2021 revealed the resident was sent to the ED and report was called to the ED to advise the resident was in route. However, review of the discharge MDS assessment return anticipated dated October 28, 2021 revealed the resident did not have one or more unhealed pressure ulcers. During an interview conducted on November 4, 2021 at 10:35 AM with the MDS Coordinator (staff #71), she stated that she missed the pressure ulcer documentation when she reviewed the resident's record and that she would immediately fixed the issue. In an interview conducted on November 4, 2021 at 11:48 AM with the Director of Nursing (staff #65), he stated that the MDS assessments need to be accurately filled out. The RAI manual instructs to review the medical record, speak with direct care staff, examine the resident, and code the presence of any pressure ulcer in the past 7 days. Review of the facility policy, Resident Assessment, Accuracy of Assessment (MDS 3.0), revealed it is the policy of this facility to ensure that the assessment accurately reflect the resident's status.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure one resident (#159) and/or the resident's representative was notified in writing of a transfer/discharge. The sample size was 2. The deficient practice could result in residents and/or their representatives not being provided a written notice of a transfer/discharge. Findings include: Resident #159 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing Health Status Note dated October 28, 2021 revealed the resident displayed shortness of breath, crackles auscultated to bilateral lungs, the Director of Nursing (DON) was notified, and the resident was sent to the ED. Review of the clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge assessment dated [DATE] revealed the resident was short of breath, unable to maintain an oxygen saturation above 88% with supplement oxygen via nasal cannula, had crackles in both lungs upon auscultation, and that the resident was transferred to the ED on October 28, 2021. The assessment included the DON was notified. However, further review of the clinical record revealed no evidence the resident and/or the resident's representative was notified in writing of the transfer to the hospital. During an interview conducted on November 4, 2021 at 10:54 a.m. with a Registered Nurse (RN/staff #51), she stated that when they send residents to the hospital they are to notify the physician, the DON, and the resident's emergency contact or responsible party. The RN stated the notifications are to be documented in the clinical record, usually on the Discharge Assessment or in the Progress Notes. After reviewing the clinical record for resident #159, the RN stated that there was no documentation that the family had been notified. In an interview conducted with the DON (staff #65) on November 4, 2021 at 11:48 a.m., the DON stated that it was his expectation that the staff complete all documentation fully and correctly and that the staff document all notifications. Review of the facility titled Transfer or Discharge, Emergency (revised December 2016) revealed emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). The policy also revealed that should it become necessary to make an emergency transfer or discharge to a hospital, the facility will notify the representative or other family member.

Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one of two sampled residents (#17) consistently received assistance with activities of daily living (ADLs). The deficient practice could result in ADLs needs not being met. Findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status of 02 which indicated the resident had severe impaired cognition. The assessment also revealed the resident was totally dependent with dressing, personal hygiene, transfer, locomotion, toilet use and bed mobility, and required supervision with eating. The MDS assessment included it was very important for the resident to choose what clothes to wear, and to go outside to get fresh air when the weather is good. Review of the Monthly Nursing Summary dated October 29, 2021 revealed the resident was able to recall the current season, location of own room, staff names and faces, and that the resident was in a nursing home. The summary also revealed the resident required extensive assistance with bed mobility and transfer, was totally dependent for toilet use, and required supervision with setup help only for eating. The summary included the resident had own teeth, did not have dentures, and needed assistance with oral hygiene. An initial observation was conducted of the resident on November 1, 2021 at 1:43 p.m. The resident was observed lying in the bed looking out the window wearing a hospital gown with food particles on the chest area. The resident's left eye was observed reddened with crusted rheum present and the resident's hair uncombed. The resident was observed to have no upper teeth and missing bottom teeth. Following this observation, an interview was conducted with the resident who stated the staff does not always have the time to assist the resident with putting in the dentures and assist with dressing because they are very busy. Resident #17 stated that she needs help putting the dentures in. The resident stated the dentures were kept in the dresser located in the corner of the room and were out of reach. The resident stated she frequently eats without the dentures which makes chewing food a little harder. Resident #17 stated she has clothes but needs help getting dressed because she cannot walk by herself. The resident stated a machine lift is used to get her out of bed and sometimes the staff does not have the time to get her up. During an observation conducted of the resident on November 2, 2021 at 8:15 a.m., the resident was observed awake, lying in the bed wearing a hospital gown. A breakfast tray was observed in front of the resident and the resident was attempting to eat the food. The resident was observed to drool from the mouth whenever the resident attempted to chew the food. The resident was also observed not have upper and lower dentures in place or have a clothing protector in place. Another observation was conducted of the resident on November 3, 2021 at 10:00 a.m. The resident was observed lying in bed looking out the window wearing a hospital gown that had food particles on it. The resident was also observed with dry drool on the chin, hair uncombed, crusted rheum to the left eye, and no dentures in the mouth. An interview was conducted with a Temporary Nursing Assistant (TNA/staff #81) at 1:35 p.m. on November 3, 2021, who stated that he only works three times a week. The TNA stated that whenever he is caring for the resident, he would get the resident up because the resident enjoyed getting dressed and watching television in the wheelchair. The TNA stated the resident was dependent for ADLs and transfer, and a Hoyer lift was used to get the resident up. Staff #81 opened the night stand and dresser and found the upper and lower dentures in a denture cup. He stated the dentures were very dry and that he would need to clean the dentures and put water in the denture cup. Staff #81 stated the resident needed help with putting in the dentures. On November 3, 2021 at approximately 1:45 p.m., staff #81 cleaned the dentures and handed them to the resident. The resident told staff #81 she needed help putting the denture in, that she cannot do it by herself. The TNA assisted the resident with the dentures and asked the resident if the dentures fits. The resident said yes and thanked the TNA for helping her. Staff #81 also opened the resident's closet which revealed various clothing available for the resident to choose from. An interview was conducted on November 4, 2021 at 12:27 p.m. with a Registered Nurse (RN/staff #82), who stated she was very familiar with the resident. The RN stated the resident was alert and oriented to person, place, and time and needed total assistance with ADLs, transfer, dressing, and locomotion. Staff #82 stated that she did not know the resident had dentures. The RN stated that her expectation is for the resident to be out of bed daily to prevent lung issues and bed sores, unless the resident refused and the refusal should be documented. A follow up interview was conducted with the resident on November 4, 2021 at 12:28 p.m. The resident stated that she likes sitting up in the chair watching television and looking out the window but that she does not get the help from the staff to get into the chair because the machine lift requires two staff. The resident stated that she likes wearing regular clothes, but sometimes the staff leaves her in the gown when she is in bed. The resident stated that she is left in the gown most of the time, because the staff are very busy and does not have the time to get her dressed. The resident stated that she does not want to bother the staff because they have other residents to care for. The resident stated that she needs assistance with putting in the dentures, that she cannot clean the dentures by herself, and that most of the time the dentures are in the cabinet. An interview was conducted on November 4, 2021 at 1:24 p.m. with the Director of Nursing (DON/staff #65), who stated he was very familiar with the resident, and that the resident was dependent with all ADLs. He stated his expectation was that residents who need help with ADLs get the help they deserved. The DON stated he expected the staff to provide the assistance needed by the residents which includes hygiene needs, putting on street clothes, oral care, and getting out of bed daily. The DON also stated that he expected the staff to ensure the residents' dentures were put in if they have dentures. A facility policy Quality of Life - Accommodation of Needs revised August 2009 stated the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. The policy included the resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. Staff shall arrange toiletries and personal items so that they are in easy reach of the resident. Staff shall help to keep hearing aids, glasses and other adaptive devices clean and in working order for the resident.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that one of five sampled residents (#1) was administered a diabetic medication per physician's order. The deficient practice could result in residents not receiving physician ordered medications. Findings include: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan initiated on April 4, 2013 revealed the resident has Diabetes Mellitus. Interventions included diabetes medication as ordered by the physician and to monitor, document, and report to the physician as needed signs/symptoms of [CONDITION(S)] and [CONDITION(S)]. A physician order dated June 4, 2020 included for [MEDICATION(S)] Solution 100 unit/ML ([MEDICATION(S)]) inject 18 unit subcutaneously at bedtime related to diabetes. Review of the Medication Administration Record (MAR) for July 2021 revealed the resident was not administer [MEDICATION(S)] at bedtime on July 22, 2021 with the code 15 as the reason which meant the blood sugar was below parameters-no insulin required. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 03, which indicated the resident's cognition was severely impaired. The assessment also revealed the resident received insulin injections during the lookback period. A review of the MAR for August 2021 revealed [MEDICATION(S)] was not administered to the resident on August 24 and 6, 2021 with the code 15 as the reason the insulin was not given. Additional review of the clinical record did not reveal an order with parameters for [MEDICATION(S)]. An interview was conducted with a Registered Nurse (RN/staff #51) on November 4, 2021 at 8:58 AM, who stated that the facility policy is to follow the physician's order as written. The RN reviewed the MAR for August 2021 and stated that according to the documentation, the [MEDICATION(S)] was not administered to the resident as ordered on August 24 and August 26, 2021. The RN also stated that there were no parameters for this medication. She stated that this was not following the facility policy. Later that morning at 10:42 AM, staff #51 reviewed the July 2021 MAR and stated that on July 22 the resident's blood glucose was documented as 149, [MEDICATION(S)] was not given, and the code for not administering the [MEDICATION(S)] was 15, which indicated the blood sugar was below parameters. The RN stated that [MEDICATION(S)] had not been administered as ordered and that this did not meet the facility policy. She further stated that the facility policy is to administer medication according to the physician's order. An Interview was conducted on November 4, 2021 at 10:47 AM with the Director of Nursing (DON/staff #65), who stated that the facility policy regarding physician's orders is to execute them as written. After reviewing the MARs, the DON stated that [MEDICATION(S)] had not been administered as ordered on July 22, 2021 and on August 24 and 26, 2021. The DON stated that the risk of not administering the insulin as ordered could be an increase in blood sugar. Review of the facility policy titled, Administering Medications, revealed medications shall be administered in a safe and timely manner, and as prescribed. The policy also revealed medications must be administered in accordance with the orders, including any required time frame.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure the physician was notified when an insulin was not administered as ordered for one resident (#1). The sample size was 5. The deficient practice could result in physicians not being notified when medications are not administered as ordered. Findings include: Resident #1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order dated June 4, 2020 included for [MEDICATION(S)] Solution 100 unit/ML (insulin [MEDICATION(S)]) inject 18 units subcutaneously at bedtime related to diabetes. Review of the Medication Administration Record (MAR) for July 2021 revealed the resident was not administer [MEDICATION(S)] at bedtime on July 22, 2021 with the code 15 as the reason which meant the blood sugar was below parameters-no insulin required. A review of the MAR for August 2021 revealed [MEDICATION(S)] was not administered to the resident on August 24 and 26, 2021 with the code 15 as the reason the insulin was not given. However, review of the clinical record did not reveal an order with parameters for the [MEDICATION(S)] or that the physician was notified the medication was not given. An interview was conducted with a Registered Nurse (RN/staff #51) on November 4, 2021 at 8:58 AM, who stated that the facility policy is to notify the physician when medications are not administered as ordered, and the notification should be documented in the progress notes. The RN reviewed the August 2021 MAR regarding [MEDICATION(S)] and stated that according to documentation the medication was not administered on August 24 and August 26, 2021. The RN reviewed the progress notes for August 24 and August 26, 2021, and stated that there was no documentation that the physician had been notified. She stated this was not following the facility policy and the risk to the resident would be that the physician is not aware of the resident's status. An additional interview was conducted on November 04, 2021 at 10:42 AM with staff #51, who stated that according to facility policy the nurse should notify the physician when a medication is not administered as ordered. The RN reviewed the July 2021 MAR and stated that [MEDICATION(S)] had not been administered as ordered on July 22, and that there was no documentation in the progress notes that the physician had been notified. She further stated that it is the facility policy is to administer medication according to the physician's order, and if it is not administered as ordered the physician needs to be notified. An Interview was conducted on November 4, 2021 at 10:47 AM with the Director of Nursing (DON/staff #65), who stated that when a medication is not administered as ordered the physician needs to be notified, and the notification documented in the progress notes. The DON reviewed the July 2021 MAR regarding [MEDICATION(S)] and stated there is no documentation that it was administered, and no documentation that the physician had been notified. He then reviewed the August 2021 MAR and stated that [MEDICATION(S)] had not be administered on August 24 and 25, 2021. He further stated that he could find no documentation in the progress notes that the physician had been notified on those dates. The DON stated that the risk of not notifying the physician could be that the physician would not be aware of the resident's status. Review of the facility policy titled, Administering Medications, revealed that medications must be administered in accordance with the orders. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

Based on observation, staff and resident interviews, clinical record reviews, and policy review, the facility failed to provide care and services to one resident (#79) with an indwelling urinary catheter, resulting in a penile ulcer and hospitalization . The facility failed to have evidence that catheter care was provided to one resident (#2). Findings include: -Resident #79 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident had a history of [REDACTED]. Physician orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the May Treatment Record, the catheterization was not started until May 15. The quarterly Minimum Data Set (MDS) assessment dated [DATE], identified that the resident required extensive assistance from one staff member for personal hygiene. The resident also required extensive assistance from two staff members for use of the toilet. A nurse progress notes dated May 20, 2012, now documented an indwelling urinary catheter was inserted per physician orders [REDACTED]. physician's orders [REDACTED]. The order also included for catheter care to be done every shift with soap and water. Nurse's notes dated May 21, 2012, documented the resident was on oral antibiotics, continued with a low grade fever, and that the physician was notified. Review of a care plan updated on May 24, 2012, identified a goal for the resident to be free from catheter related trauma. The interventions included for staff to monitor for signs and symptoms of discomfort on urination and frequency, and to monitor/document for pain/discomfort related to catheter use. Further review of the clinical record revealed there was no documentation that catheter care was provided every shift as ordered from May 21 through May 31, 2012. The next nurse's note was written on June 4, 2012. The late entry note stated the resident's Foley (urinary) catheter bag was changed per physician orders. The note further documented the catheter was patent with no signs of redness, swelling or drainage noted to the penis. The note was signed by the assistant director of nursing. Another late entry nurse's note dated June 6, 2012 at 4 p.m., included that the resident was noted to have a penile tear around the catheter site and the skin was red around the head of the penis with bloody drainage and a foul odor was present. The note included the physician was notified. However, there were no orders or interventions to address the penile tear. There was also no documentation that catheter care was provided every shift for the first week in June 2012. In addition, there was no further skin assessment documentation of the condition of the resident's penis from June 6 after 4 p.m., until June 7 on the evening shift. A nurse's note dated June 7, 2012 revealed the following, "...Vital signs: blood pressure 128 over 58, heart rate 98, respirations 32, temperature 100.7 degrees and oxygen level was 89 percent on room air. This nurse was called into resident's room by the aide on duty. Resident was lying in bed in fetal position moaning. Hard to arouse. Upon questioning the resident admitted having pain in groin area. Inspected private area. Noticed blood tinged urine in Foley (urinary) catheter. At Foley insertion site, this nurse saw black/dark green tissue with purulent drainage and dark flapping skin pieces, foreskin had two fluid filled pockets. Strong malodorous scent noted. Notified physician of condition. Got orders to send resident to emergency department...Emergency services were called and arrived at around 4:30 pm..." A review of the Hospital emergency department report dated June 7, 2012, at 5:55 p.m., revealed the following information: "Discontinued urinary catheter from (facility) that was placed on May 20, 2012, per report received. Noted very strong foul odor upon discontinuing. Place new #18 French catheter with some discomfort. Patient moaning in pain. Noted yellow urine with sediment. Patient arrived in emergency room via emergency medical service with fever of 100.2 and ulcer to penile region. Patient pale, lethargic and does not answer questions...noted penile region black, necrotic with drainage. Wound assessment: Skin abnormally description/location: ulcer on penile, wound was present on admission unstageable wound minimal amount of green purulent and yellow drainage with foul odor. Wound is black. Wound size: 2 centimeters (cm) length by 1.5 cm width. Patient's urethra meats region is black necrotic, foul odor, noted greenish drainage. Penile head is inflamed and red in color..." The resident was not readmitted back to this facility. However, further review of the clinical record revealed a nurses's note dated June 8, 2012, completed by a LPN, that included the following documentation: "It was reported to this LN on Wednesday night that res's cath was cutting into his penis, but that a dressing had been applied to penis. Noticed that a fax had been sent to MD already, aides did not report anything wrong with drsg or cath, and res sleeping well that night." The facility was unable to provide any ongoing assessments of the penis area, nor any documentation of care provided, nor any interventions implemented to address the penile tear once it was identified. An interview was conducted on June 13, 2013, with a certified nursing assistant (CNA) who stated that if a resident was experiencing any tenderness, pain or redness around a catheter, it should be reported to the nurse immediately. An interview with the ADON was conducted on June 13, 2013. The ADON stated that she could not explain why the catheter care documentation could not be found. She stated that she documented the progress notes on June 4, 2013, because the nurse caring for the resident that day had asked her to change the catheter bag and she was the one to assess the resident on that day. A review of the a facility policy regarding catheter care revealed that any complaints the resident may have of burning, tenderness, or pain in the urethral area must be reported. -Resident #2 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. According to hospital records from June 18, 2010, the resident had a supra pubic catheter placed related to chronic UTIs. A review of physician's orders [REDACTED]. A review of the resident's TAR from March and April 2013 revealed that the resident did not receive catheter care on six different shifts in March and did not receive catheter care on 13 shifts in April. During an interview conducted with a CNA on June 12, 2013 at 12:41pm, it was revealed that the resident had a supra pubic catheter and was dependent on staff to provide the catheter care. During an interview conducted on June 13, 2013 at 12:56pm, a Registered Nurse (RN) stated that catheter care is something that is documented as being done and is documented either on the TAR or Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to ensure that adequate and direct supervision was provided to prevent a second fall that resulted in actual harm for one resident (#23). The sample size was 4. Findings include: Resident #23 was admitted on [DATE], with [DIAGNOSES REDACTED]. Per an admission Minimum Data Set (MDS) assessment dated [DATE], the resident was assessed to make her needs known and be understood and able to understand others. The resident required the assistance of one person to ambulate. Per a care plan dated September 29, 2011, the resident was identified to be at risk for falls and approaches were implemented, including verbal reminders not to ambulate/transfer without assistance, providing toileting assistance, and keeping the call light within reach at all times. Per the MDS assessment dated [DATE], the resident continued to require staff assistance with ambulation. In addition, the resident continued to able to make herself understood and understand others. The care plan for falls dated September 29, 2011, was reviewed and the previous interventions remained in place. In a review of a nursing note entry dated February 13, 2012, with the documented time as 7:15 p.m., the following information was documented by a Licensed Practical Nurse (LPN) and identified as staff #1. According to the entry a Certified Nursing Assistant (CNA) identified as staff #2 had reported that she had found the resident on the floor and reported the incident to staff #1. Staff #1 then went to the resident's room and assessed the resident. The resident complained of pain in her head and no visible injury was noted. The resident was assisted to the wheelchair by staff #1 and staff #2 as well as an additional CNA. The resident began to complain of pain in her hip and thigh. Staff #1 then documented that a decision was made to send the resident to the emergency room for further evaluation of the pain. Continued in the February 13, 2012, nursing note entry was that staff #1 informed staff #2 and the additional CNA to remain with the resident while transport was being arranged. A call was placed to the physician's office for approval of transport and arranged for transport. Staff #2 returned to the nursing station and reported the resident had fallen a second time. Staff #1 returned to the resident's room and assessed the resident and documented the resident was alert and oriented to self and place. In a further review of the nursing notes there was an additional entry dated February 14, 2012, related to the falls that occurred on February 13, 2012. This entry contained much of the same information as documented in the earlier nursing note and again staff #1 documented that she advised staff #2 to stay with the resident after the first fall. While staff #1 was notifying the physician and arranging emergency transport, staff #2 returned to the nursing station and reported the resident had fallen a second time, which was approximately 10 minutes after the first fall. Staff #1 then entered the resident's room and found the resident face down on the floor with blood on the floor near the resident's face. Also documented was that the resident's right arm appeared to be in an awkward position. Emergency personnel arrived on the scene and the resident was transported on an emergent basis. An interview was conducted with staff #1 on March 22, 2012. She stated she was told by staff #2 that resident #23 had been found on the floor in her room and the resident was assisted from the floor to the wheelchair. Within minutes staff #1 stated staff #2 returned to the nursing station and told her the resident had fallen again and was on the floor in her room. During the interview with staff #1 she stated that although she had not specifically directed staff #2 to stay with the resident, she presumed staff #2 would do so. Staff #1 stated the resident was not supervised from the time of the first fall until the time of the second fall. An interview was conducted with staff #2 on March 22, 2012. She stated she had found the resident on the floor on February 13, 2012, and quickly went and told staff #1. Together they returned to the resident's room and the resident was moved from the floor to the wheelchair. Staff #2 stated she then left the resident's room to finish care that she had been providing to another resident who was now hollering out. Within minutes staff #1 heard a noise from the room of resident #23 and when she entered the room she found the resident face down on the floor. She then found staff #1 and told her of the second fall. Staff #2 stated she was not told by staff #1 to stay with the resident after the first fall and if she had been directed to stay that is what she would have done. Staff #2 stated the resident was not supervised from the time of the first fall until the time of the second fall. As noted in the two nursing note entries dated February 13 and 14, 2012, as well as interviews with staff #1 and #2 who responded to the resident at the time of the fall, the resident was documented to have had an unwitnessed fall. Despite the fact that the fall was unwitnessed, the fact that the resident was assessed as able to make her needs known, and the fact that the resident was complaining of pain in her head, adequate and direct supervision was not provided and a second fall occurred within minutes that resulted in facial injuries and a fracture of the humerus. Multiple interviews were conducted with administrative staff on March 21 and 22, 2012. Staff acknowledged the discrepancies of the interviews of staff #1 and staff #2 regarding whether staff #2 was directed to stay with the resident after the first fall. Administrative staff did state the resident was not supervised from the time of the first unwitnessed fall until the second fall that occurred within minutes. A facility policy related to falls included the following, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try to minimize complications from falling."

Based on observations, staff interviews, reviews of a closed clinical record, review of hospital records, facility policy and procedures and other facility documentation, the facility failed to ensure that the resident's environment was free of an accident hazard, as evidenced by the front entrance sloped directly to a step to the driveway that allowed one resident (#80) to fall and sustain an injury. Findings include: Resident #80 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Physician's Progress Notes dated October 14, 2009, revealed a [DIAGNOSES REDACTED]." A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident required limited assistance with locomotion on and off the unit. The limited assistance indicated that the resident was highly involved in the activity and received physical help three or more times. The MDS documented that help was provided only one to two times during the previous seven days. A Physician's Progress Note dated June 30, 2010, revealed that the resident was seen by the physician. The physician documented that the resident had appeared more confused. The diagnostic impressions included fever and delirium. A Physician's Progress Note dated July 6, 2010, revealed that the change in the resident's condition had been reported to the physician. On July 6, 2010, the resident had improved but was not back to her baseline functional level. A review of the clinical record revealed no nursing documentation between July 1 and July 23, 2010, to reflect the ongoing changes in the resident's mobility or confusion and any identified need to vary supervision of the resident. A review of the Nurses Notes dated July 23, 2010, revealed that the resident had fallen and was sent to the emergency room for treatment. Further review of the closed clinical record revealed no history of wandering or attempts to exit the facility prior to July 23, 2010. A review of facility documentation revealed that on July 23, 2010, the resident "...wheeled herself through the front door and out onto the porch. She went off the step and landed on the front part of her body. Legs straight out and arms at her side..." A review of the physician's orders [REDACTED]. A review of the hospital record dated July 23, 2010, revealed that the resident was initially evaluated at a local hospital emergency room and then flown by helicopter to another hospital. A review of the hospital History and Physical dated July 23, 2010, revealed that the resident was transferred from the emergency room after a fall and that the resident had a facial fracture. The report documented that a physical exam of the head revealed that the resident had "...raccoon's eyes, with contusion and with laceration..." The document also revealed that "...There are noted to be multiple facial fractures by report..." An observation was conducted on January 12, 2011, of the front entrance to the facility. The observation revealed that the front entrance/exit door was an automatic door that would open when a person approached the door. Directly outside the door, the surface of the ground was made of a gray concrete. The gray concrete surface had a gradual slope that allowed a wheelchair that exited through the door to roll straight down the slope toward the step/curb to the driveway. The step/curb was approximately seven to eight inches tall and was also a gray concrete color. Below the step/curb was a gray concrete slab and beyond the concrete slab was a blacktop circular drive way with sparse loose black gravel. When exiting through the front door, to the right of the step/curb was a gray concrete ramp. A rail separated the ramp from the step/curb. A gate was observed between the front door and the step/curb and a railing separated the step/curb from the ramp. A second gate was observed between the front door and the ramp. During an interview conducted at the time of the observation, the administrator stated that the gates between the doorway and the step and the doorway and the ramp were not present on July 23, 2010. She also stated that the facility Quality Assurance team looked at the front entrance after the resident fell and determined that to prevent such accidents from reoccurring gates were needed. During the interview conducted on January 12, 2011, the administrator reported that on July 23, 2010, between 2:00 and 3:00 p.m., she was standing in the doorway to the Activity room. The administrator also reported that she had seen the resident in the hallway outside the activity room. An observation of the facility revealed that the doors to the Activity room were across the hallway from the front entry way that lead to the front door of the facility. The front entry way was approximately 20 to 30 feet from the hallway to the front door. The administrator stated that she looked toward the front door and saw something pink on the ground in the driveway. She further stated that when she looked closer she saw it was a resident and called for a nurse. She said that she had not noticed the resident going out the door. During an interview conducted at 2:18 p.m. on January 12, 2011, a licensed practical nurse stated that on July 23. 2010, between 2:00 and 3:00 p.m. during the staff meeting the resident entered the activity room where the meeting was being held. The nurse also stated that the maintenance man saw the resident headed toward the front door and redirected the resident. She further stated that the resident was brought into the activity room, placed at a table and given coffee. The nurse reported that she did not notice when the resident left the room. The nurse said that later on during the meeting she heard the administrator call out for a nurse because the resident had fallen. She also said that when she responded, she saw the resident laying face down on the black surface in the driveway beyond the step/curb. During an interview conducted at 9:35 a.m. on January 13, 2011, the maintenance man reported that on July 23, 2011, he had seen the resident wheeling toward the front door. He stated that he went to redirect the resident, and was assisted by a nurse. He also stated that he did not see the resident go out the door later. During an interview conducted on January 13, 2011, a nurse who stated that she was assigned to care for the resident on July 23, 2010, stated that she was not in the area near the front doors and had not seen the resident exit the facility. Interviews were conducted on January 13, 2011, with two Certified Nursing Assistants who stated that they were working in the facility between 2:00 and 3:00 p.m. on July 23, 2010, both CNAs stated that they had not seen the resident exit through the front door, but they had seen the resident in the hallway outside the activity room prior to her fall. A review of the facility's Safety and Supervision of Residents policy and procedure revealed "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities." The document also revealed that "Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment." and "The type and frequency of resident supervision may vary...over time for the same resident. For example, resident supervision may need to be increased... if there is a change in the resident's condition..."