Every finding on record at Heartland Rehabilitation and Care Center

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff washed their hands between dirty and clean tasks, and before handling clean equipment for one of two meals observed. The findings include: During a concurrent observation and interview on 07/30/2025 at 8:51 AM, this surveyor observed Dietary Aide (DA) #1 push a cart of pitchers without gloves on, which contaminated her hands. Without washing her hands, DA #1 picked up a coffee bag and placed it into the coffee basket to prepare coffee for the residents for lunch. This surveyor asked DA #1 what she should have done after touching dirty objects and before handling clean equipment. DA #1 stated she should have washed her hands. During a concurrent observation and interview on 07/30/2025 at 9:54 AM, this surveyor observed DA #2 lift the trash can lid and throw away tissue paper without gloves on, which contaminated her hands. Without washing her hands, DA #2 picked up a bag of tea and placed it into a brew basket to brew and serve to the residents for lunch. This surveyor asked DA #2 what she should have done after touching dirty objects and before handling clean equipment. DA #2 stated she should have washed her hands. During a concurrent observation and interview on 07/30/2025 at 10:10 AM, this surveyor observed DA #1, without gloves, push a cart full of dirty dishes out of the way, which contaminated her hands. DA #1 picked up clean plates from the dish rack, placing her fingers on top of the plates where food would be placed. When she was ready to place the plates into the plate warmer, this surveyor asked DA #1 what she should have done after touching dirty objects and before handling clean equipment. DA #1 stated she should have washed her hands. During a concurrent observation and interview on 07/30/2025 at 10:30 AM, this surveyor observed DA #2 turn on the sink faucet to fill a pitcher without gloves on, then turn the water off, contaminating her hands. Without washing her hands, DA #2 picked up glasses by their rims and placed them on the counter. DA #2 then poured thickened liquid into the glasses to be served to the residents who required thickened liquid. DA #2 stated she should have washed her hands. During a concurrent observation and interview on 07/30/2025 at 12:14 PM, this surveyor observed Dietary [NAME] (DC) #3, without gloves on, pull her blouse down, contaminating her hands. Without washing her hands, DC #3 picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to serve to the residents on pureed diets for lunch. DC #3 stated she should have washed her hands. A review of a facility policy titled, “Handwashing and Glove Usage in Food service,” indicated hands should be washed as often as possible, and that it was important to wash hands before starting to work, after leaving and returning to the prep area and after touching anything else such as dirty equipment and work surfaces, as often as needed during food preparation, and when changing tasks.

Based on observation, interview, and record review, the facility failed to ensure foods stored in the freezer and dry storage area were covered, sealed, dated, and were stored in to prevent potential food borne illness for resident who received meals from 1 of 1 kitchen, expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchens, and dietary staff washed their hands before handling clean equipment and food items to prevent potential food borne illness for residents. The failed practices had the potential to affect 66 residents who receive meals from the kitchen. The findings are: 1. On [DATE] at 12:50 PM, the following items were noted on a shelf in the freezer, there were no dates of when the food items were received or when opened: a. An opened box of cheese omelets. The bag was not sealed or dated when opened. b. An opened box of egg patties. The box was not covered, sealed, or dated when opened. c. An opened box steak fingers. There was no open date on the box. d. An opened box of chocolate chip cookies. The box was not covered or sealed. e. An opened box of bread sticks. The box was not covered or sealed. 2. On [DATE] at 12:30 PM, the following observations were made on the bread rack and on the rack in the storage room: a. There were 13 bags with 8 counts of hot dog buns in each bag on the bread rack with an expiration date of [DATE]. b. A bag of bread was on the bread rack with an expiration date of [DATE]. c. A box of tea leaves on the rack had an expiration date of [DATE]. d. Four of 4 -46 fluid ounce cartons of nectar lemon flavor were on the rack with an expiration date of [DATE]. 3. On [DATE] at 04:27 PM, Dietary Employee (DE) #1 was wearing gloves on her hands when she picked up bags of sandwich buns and placed them on the counter. DE #1 untied a bag of sandwich buns that were on the counter, contaminating the gloves on her hands. Without changing gloves and washing her hands, DE #1 removed buns from the bag, placed them into a pan to be used in pureeing barbeque sandwiches to be served to the residents who required pureed diets for supper meal. At 04:30 PM, the DE #1 removed gloves from her hands. Without washing her hands, she picked a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets. At 04:31 PM, as DE #1 was about to place diced chicken into a blender, to be ground and use in making barbeque sandwiches to be served to the residents on mechanical soft diets, the Surveyor immediately stopped DE #1 and asked, Should you have done after touching dirty objects equipment and before handling food items? DE #1 stated, I should have washed my hands. 5. A facility policy titled Handwashing and Glove Usage in Food Service documented, Food handlers must wash their hands: Before starting work .After leaving or returning to the kitchen prep area and after touching anything else such as dirty equipment and work surfaces.

Based on observation, interview, and record review, the facility failed to ensure mechanical closets to the electrical and air conditioning rooms were locked to prevent residents from entering. The facility failed to lock a private bathroom on 400 Hall that did not have a call light or pull cord light to allow residents to call for assistance which had the potential to affect 9 400-Hall residents that can ambulate or self-propel and failed to transfer residents in an appropriate manner to prevent falls or injuries. The findings are: 1. On 04/22/2024 at 09:59 AM, the Surveyor observed a door labeled Mechanical Room slightly ajar on the front, right hand side of 400 Hall. The Surveyor opened the door and observed air conditioning equipment, boxes on the floor, and a rolling cart of tools. The Surveyor exited the room and walked across the hall to another unlocked door labeled Mechanical Room with air conditioning and light equipment. 2. On 04/24/2024 at 01:40 PM, the Surveyor asked to speak with the Maintenance Supervisor, and he identified 400 Hall Mechanical Rooms as the air conditioning and electrical rooms. The Surveyor asked if it was their procedure to leave the mechanical room doors unlocked and/or open. The Maintenance Supervisor said that the doors are supposed to remain locked so that residents cannot get into the air conditioner or electric panels because it is hazardous. 3. On 04/24/2024 at 02:20 PM, the Surveyor spoke with the Director of Nursing (DON) and asked what the procedure was for safely maintaining mechanical or maintenance closets in the facility. The DON told the Surveyor that no maintenance or mechanical closets in the building should be left open or unlocked at any time. 4. On 04/24/2024 at 01:16 PM, the Surveyor observed a door marked Private Restroom on 400 Hall, with the door slightly ajar. The Surveyor observed a toilet on the right, sink, boxes stacked against the wall to the right of the toilet containing clear fluid in jugs, and the Surveyor noted there was no call light button or pull cord in the private bathroom. a. On 04/24/2024 at 01:46 PM, Licensed Practical Nurse (LPN) #1 was asked to accompany the Surveyor to 400 hall, and the Surveyor pointed out the open door labeled Private Restroom. LPN #1 told the Surveyor that LPN #1 did not know there was a bathroom on 400 Hall. The Surveyor asked if a 400-Hall resident fell in the bathroom what procedure how would the resident get assistance. LPN #1 said they would not be able to use a call button or pull cord because there was not one so they would not be able to call for assistance. LPN #1 confirmed the bathroom door should be kept locked. b. On 04/24/2024 at 02:25 PM, the Director of Nursing (DON) was asked what procedure residents use if they fell in a private bathroom without a pull cord or call light button. The DON told the Surveyor there is supposed to be a pull cord light in any bathroom. If a resident is on the floor, they cannot reach us, and a pull cord should be assessable standing, sitting, or lying in the floor for residents. The DON confirmed they do not have a mechanical closet, call light or bathroom policy. 3) On 02/22/2024 at 12:48 PM, Certified Nursing Assistant (CNA) #1 entered Resident #30's room. CNA #1 did not have a gait belt to use for transferring Resident #30 from wheelchair to bed. CNA #1 placed arms underneath Resident #30 s' arms then with left hand held onto back of Resident #30 s' pants as Resident #30 was lifted from the wheelchair. As CNA #1 turned to the left, Resident #30 was not close enough to the edge of the bed. CNA #1 realized this as Resident #30 was unable to be placed on the edge of the bed. CNA #1 attempted three times to place resident on the bed. With each attempt to place Resident #30 on the edge of the bed, CNA #1 would try to take a step towards the bed unsuccessfully. The third attempt Resident #30 became weak legged and assisted to the floor. After assisting Resident #30 to the floor, CNA #1 then used a cell phone to call for help. After Resident #30 was on the floor, the Surveyor saw MDS/LPN #1 exit the MDS office. Survey informed MDS/LPN #1 that CNA #1 needed help with Resident #30. CNA #2 came into room carrying a gait belt. Resident #30 was placed back into the wheelchair. CNA #30 placed the gait belt around Resident #30's waist and threaded the end through the metal teeth to secure the gait belt. Resident #30 was then transferred to the bed. A. On 04/24/2024 at 08:10 AM, the Social Worker confirmed that a gait belt was required when transferring a resident from wheelchair to bed. The gait belt is part of the uniform. B. On 04/24/2024 at 9:09 AM, CNA #2 confirmed that a gait belt was required when transferring a resident from wheelchair to bed. C. On 04/24/2024 at 9:12 AM, LPN #2 confirmed a gait belt is kept on the linen cart, that Resident #30 is a 2 person assist from the ADL sheet, and that the gait belt is used to not pull on the resident's arms. D. On 04/24/2024 at 11:00 AM, the DON provided the following: 1) Resident Transfers Inservice and Clinical Check Offs dates: 05/03/2023; 08/21/2023; 12/13/2023; and 03/23/2024. 2) Gait Belt Competency Skills Checklist which states Understand that using a gait belt improves patient safety .Using gait belts ca help prevent staff injury and provides a secure point for staff to hold onto the patient while assisting with transfers and ambulation .Applying and Using the Gait Belt: Wrap gait belt around the patient at waist level.; Pull strap through buckle and adjust so it is snug but not uncomfortable making sure o can place your hand between the patient and the belt .Position yourself on the strong side of the patient ( on the weaker side if a cane or walker will be used.); Slide your hands upwards beneath the belt.; Help the patient to a standing position. Patient should stand fully erect with shoulders back and looking forward.; Position yourself to the side and slightly behind the patient.; Assist with transfer or ambulation . 3) Transfer Activities which states .Procedure: Transfer from bed to wheelchair 1. Obtain assistance of another individual if necessary for safe transfer .Apply transfer belt snugly around the resident's waist, positioning the buckle off center. Tuck excess strap under the belt. Grasp the belt from underneath to provide support during the transfer .Hold the transfer belt from underneath straighten your hips and legs slightly and lift the client to a standing position on a count of three . E. On 04/24/2024 at 4:50 PM, the DON confirmed that a gait belt had not been used on Resident #30.

Based on observation, interview, and record review, the facility failed to ensure meals were served in a method that maintained the appearance pureed food items and of hot food product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. This failed practice had the potential to affect 19 residents who receive meal trays in their rooms on the 100- Hall, 5 residents who receive meal trays on the 200- Hall, 4 residents who receive meal trays in their room on the 300- Hall, 14 residents who receive meal trays on 400- Hall. The findings are: 1. Resident #18 had diagnoses of End stage renal disease, Malnutrition, and Metabolic encephalopathy. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/09/2024 documented that the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). The care plan with a revision date of 03/18/2024 documented, .Problem: (Resident #18) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) old CVA (Stroke) .Approaches/Tasks: .o Eating: Resident requires set-up assistance with meals/eating . A physician's order dated 02/16/2024 documented, .[named brand of super calorie shakes] (Super calorie) diet Regular texture, Thin consistency, for add 2 shakes at lunch and dinner prefers vanilla . On 04/23/2024 at 09:27 AM, the Surveyor asked Resident #18, How is the food that you receive here at the facility? Resident #18 stated, The food is not good. The Surveyor asked Resident #18, What is specifically wrong with the food? The Resident stated, It is usually cold, and it does not taste good. 2. On 04/24/2024 at 12:26 PM, an unheated food cart that contained trays for lunch trays was delivered to the 300 -Hall, by Certified Nursing Assistant (CNA) #2. At 12:39 PM, immediately after the last resident was served in their room on 300 -hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary supervisor with following result: Lasagna with meat sauce 110 degrees Fahrenheit. 3. On 04/24/2024 at 12:30 PM, an unheated food cart that contained trays for lunch trays was delivered to the 100- Hall by the CNA #3. At 12:41 PM, immediately after the last resident was served in their room on 100 Hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor with following result: Lasagna with meat sauce 111 degrees Fahrenheit. 4. On 04/25/2024 at 07:20 AM, an unheated food cart that contained trays for breakfast trays was delivered to the 400 -Hall, by the CNA #3. At 07:58 AM, immediately after the last resident was served in their room on 400 -Hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor with following result: a. Pureed scrambled eggs 105 Degrees Fahrenheit. b. Pureed sausage 102 degrees Fahrenheit. c. Pureed oatmeal 108 degrees Fahrenheit. d. Scrambled eggs 110 degrees Fahrenheit. 5. On 04/25/2024 at 07:30 AM, the following pans that contained pureed diets food items were on the steam table: a. A pan of pureed sausage. The appearance was runny. b. A pan of pureed oatmeal. The appearance was runny. c. A pan of French toast. The appearance was running. d. A pan of pureed eggs. When plated by the Dietary Supervisor to serve to the residents who required pureed diets for breakfast. All pureed food items ran together. 6. On 04/25/2024 at 07:33 AM, the Surveyor asked CNA #1, who was assisting residents in the dining room, to describe the appearance of the pureed diets served to the residents who required pureed diets for breakfast. She stated, They don't look good. They were running together. 7. On 04/25/2024 at 07:34 AM, the Surveyor asked CNA #2, who was assisting residents in the dining room, to describe the appearance of the pureed diets served to the residents who required pureed diets for breakfast. CNA #2 stated, I wouldn't eat it. They shouldn't be running together. CNA #3 stated, They ran together. 8. On 04/25/2024 at 07:36 AM, the Surveyor asked CNA #4, who was assisting residents in the dining room, to describe the appearance of the pureed diets served to the residents who required pureed diets for breakfast. CNA #2 stated, They ran together. I wouldn't eat it. 9. On 04/25/2024 at 07:55 AM, an unheated food cart that contained trays for lunch trays was delivered to the 100 -Hall, by CNA #7. At 08:09 AM, immediately after the last resident was served in their room on 100- hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary supervisor with the following result: a. Scrambled eggs 110 degrees Fahrenheit. b. sausage 99 degrees Fahrenheit. 10. On 04/25/2024 at 08:15 AM, the Surveyor asked the Dietary Supervisor to describe the appearance of pureed food items served to the residents for breakfast. She stated, They could had been thickened a little.

Based on observation, interview, and record review, the facility failed to ensure residents received dental care to promote good hygiene and prevent nutritional and dental complications for 1 (Resident #14) sampled resident. This failed practice had the potential to affect 7 residents on 400-Hall that require complete dental assistance. The findings are: 1. Resident #14 had diagnoses of Cerebral infarction, Absence of right leg below the knee, and Type II diabetes mellitus with foot ulcer. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 01/19/2024 indicated a Brief Interview for Mental Status [BIMS] score of 15 (13-15 suggest cognitively intact). Resident #14 required maximum assistance for eating, oral hygiene, dressing and personal hygiene. Resident #14 is dependent for toileting and bathing. a. On 04/22/2024 at 11:43 AM, the Surveyor observed an off white, and a blue and white, toothbrush resting on the bathroom sink behind the faucet, and the blue and white brush is above the faucet with bristles touching the porcelain. Resident #14 said that staff is responsible for brushing his/her teeth. Resident #14 was unable to identify resident's toothbrush. b. On 04/23/2024 at 09:39 AM, the Surveyor observed an off-white toothbrush resting behind the bathroom faucet, and a blue and white brush resting above the faucet with bristles touching the porcelain. The toothbrushes appear to be in the same position as yesterday. Resident said no when asked if staff assist in brushing teeth in the morning, after meals or at bedtime. Resident #14 was asked who brushes his/her teeth and he/she said, [family member] does. The Surveyor asked if [family member] comes daily and brushes his/her teeth and Resident #14 said, On weekends. c. On 04/24/2024 at 01:00 PM, Certified Nursing Assistant (CNA) #4 was asked to accompany the Surveyor to room [ROOM NUMBER]-B and assist in identifying toothbrushes. CNA #4 told the Surveyor that she sees two toothbrushes making contact with the sink and did not know which toothbrush belonged to Resident #14. The Surveyor asked what procedure was normally used to store toothbrushes and CNA #4 said the facility has plastic toothbrush holders, and they can write the residents name on it for them. CNA #4 told the Surveyor that residents should be offered assistance brushing their teeth after meals, at bedtime, and as they need or want it done. The Surveyor asked if residents family assisted her with dental care how often would that be based on when they visit. CNA #4 said [family member] visits on Sundays. d. On 04/24/2024 at 02:58 PM, the Director of Nursing (DON) was asked who is responsible for assisting residents with dental care, and how often that service should be provided. The DON said CNAs should provide dental care on a regular basis, after meals, bedtime, and as needed, but anyone that is available should assist. DON said, It is an activity of daily living [ADL], and we are here to assist with it. The DON said they did not have an activity of daily living policy but could provide an in-service. e. On 04/24/2024 at 03:21 PM, the DON provided an in-service titled Oral and Dental (dated, 04/13/2023) documenting .Oral Hygiene Importance Proper oral hygiene and dental care are vital to the health and wellbeing of the nursing home resident .Why is Oral Care Neglected? Staff not paying attention to residents' individual needs .Best Practices-Oral Care . Should be done at least twice a day .

Based on observation, interview, and record review, the facility failed to date humidifier bottles to ensure nursing staff changed humidifier bottles weekly to prevent respiratory infections. This failed practice had the potential to affect 2 residents living on 400 Hall using oxygen with humidifier bottles. The findings are: 1. Resident #59 had diagnoses of Cerebrovascular disease, Pressure ulcer of the sacral region, and Schizophrenia. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 04/04/2024 indicated a Brief Interview for Mental Status score [BIMS] of 14 (13-15 indicates cognitively intact). a. A Care Plan (Revision, 03/27/2024) documented, .administer oxygen as ordered, change all disposable respiratory equipment clean/replace filter every Sunday night shift and bag and date . b. On 04/22/2024 at 11:32 AM, the Surveyor observed Resident #59 receiving 2 liters of oxygen via nasal cannula and an undated humidifier bottle. c. On 04/23/2024 at 10:20 AM, the Surveyor observed Resident #59 receiving 2 liters of oxygen via nasal cannula, with tubing dated 04/22/2024, and a humidifier bottle that is not dated. d. On 04/23/2024 at 03:13 PM, Resident #59 was receiving 2 liters of oxygen via nasal cannula using a humidifier bottle that was not dated. e. On 04/24/2024 at 02:12 PM, Licensed Practical Nurse (LPN) #1 was asked to accompany the Surveyor to room [ROOM NUMBER] and assist in checking the humidifier bottle for a date. LPN #1 removed the humidifier bottle and looked on all sides. LPN #1 told the Surveyor that it's not dated. The Surveyor asked what process was used when changing a humidifier bottle. LPN #1 confirmed that the humidifier bottle should be changed every 7 days, on Sunday, and the humidifier bottle should be dated. When the Surveyor asked why staff were expected to date humidifier bottles LPN #1 told the Surveyor to make sure the same bottle is not there over a week, or 7 days. f. On 04/24/2024 at 02:29 PM, the Director of Nursing (DON) was asked by the Surveyor to describe the process for changing out humidifier bottles on an oxygen concentrator. The DON reported that staff are expected to change humidifier bottles every 7 days, on Sunday nights. The DON was asked to provide the facility's oxygen policy. g. On 04/24/2024 at 03:59 PM, the DON provided a policy titled Oxygen Administration documenting, .Care and Use of Disposable Humidifiers: a. Change prefilled disposable humidifiers weekly .

Based on observation, interview, and record review, the facility failed to ensure ice packs were maintained in cooler bags at the bedside for residents on thickened liquids to ensure fluids were appetizing for the residents to help prevent dehydration and weight loss. This failed practice had the ability to affect two residents on 400-Hall on thickened liquids. The findings are: Resident #39 had diagnoses of Dysphagia, Chronic obstructive pulmonary disease, and Dementia. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 03/30/2024 documented a Brief Interview for Mental Status [BIMS] score of 6 (0-7 suggest severe cognitive impairment). Resident #39 required set up assistance with meals. A Physician Orders (Dated, 07/20/2023) documented, .Super calorie diet Pureed texture, Nectar consistency . A Care Plan (Revised, 10/10/2023) documented, .[Resident #39] has difficulty swallowing related to dysphagia and at risk for weight loss. Ensure that resident receives nectar thickened liquids as ordered . Resident #39 had potential for nutritional deficits related to meal consumption varies . Resident #39 will receive adequate nutrition as evidenced by weight stable. (Revision on: 7-20-23) super calorie diet with pureed texture and nectar thick . On 04/22/2024 at 11:21 AM, in room [ROOM NUMBER] the Surveyor observed a blue cooler bag containing about an inch of room temperature water, 2- 4 oz thicken lemon waters, and 1- 4 oz thicken cranberry cocktails on a bedside table beside Resident 39's recliner. There is no hydration in reach of the bedside. On 04/22/2024 at 01:15 PM, Certified Nursing Assistant (CNA) #5 was overheard offering to place an unopened 4 oz container of thickened Tea in the cooler bag for later. The Surveyor asked CNA #5 to check the closed blue cooler bag and CNA confirmed there is melted water, and no ice pack. The CNA confirmed that ice packs are supposed to be checked every morning. On 04/24/2024 at 12:55 PM, the Surveyor was visiting with Resident 39 and observed 4-4 oz thickened tea, 4-40 thickened lemon waters, and 2-4 oz thickened cranberry cocktails without dates. There is about an inch of room temperature water resting in the bottom of the cooler bag, and no ice pack. Resident #39 told the surveyor he prefers his drinks to be cold, but not icy or warm. On 04/24/2024 at 02:05 PM, CNA #4 was asked to accompany the Surveyor to room [ROOM NUMBER] and check the blue cooler bag resting on a table across from Resident 39's bed. The Surveyor asked what process is used to maintain ice packs and drinks in the cooler bag. CNA #4 told the Surveyor that when staff rounds the halls everyone is supposed to check for ice packs and thickened liquids in the coolers, because residents are more likely to drink fluids if they are cool. CNA #4 reported that thickened liquids are provided by the kitchen, and occasionally if a resident does not drink what is on their tray it may go into a cooler bag. On 04/24/2024 at 02:29 PM, the Director of Nursing (DON) was asked who is responsible for maintaining the ice packs and coolers in resident rooms to maintain hydration, and the DON said Restorative is supposed to round and check them every morning after breakfast. Any staff member that opens a cooler bag and finds that it needs ice or thickened liquids is expected to fix it for the resident. The DON said they do not have a hydration policy to address thickened liquids at the bedside, and the kitchen does not put dates on the 4 oz containers, because they go by the expiration date.

Based on observation, record review, and interview, the facility failed to ensure ongoing communication and collaboration with the Dialysis Facility for 1 (Resident #17) reviewed for End Stage Renal Disease/Dialysis services, according to a list provided by Director of Nursing (DON) on 04/06/23. The findings are: 1. Resident #17 was admitted on [DATE] with diagnoses of End Stage Renal Disease, Anxiety Disorder, Essential Hypertension, Anemia, And Dependence On Renal Dialysis. The Medicare Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/23 documented a score of 10 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). Resident needs extensive assist of one person with toileting and eating and is totally dependent on 2 persons for transfers. a. During a review of Resident #17's Electronic Health Record (EHR) on 04/06/23 at 3:11 PM, the Surveyor was unable to locate any lab results in the record that had been completed in the Dialysis Unit or communication of lab results that were completed in the Nursing Facility with an order date of 02/09/23, per Progress Note: Licensed Practical Nurse (LPN) notified on call Physician of Potassium level and orders received from Physician to treat low Potassium. The Surveyor was unable to locate the communication between the facility and the Dialysis Center. b. The Physician's Order with an order date of 03/27/23 documented, . DIALYSIS - 3X [times] week 0530 [5:30] M, W, F [Monday, Wednesday, Friday] @ [at] [Dialysis Center] . Review of the record showed no Dialysis communication forms, or dialysis treatment run sheets, which provide communication between the nursing facility and the dialysis facilities. c. On 04/06/23 at 2:45 PM., the Surveyor asked LPN #2, Where are the communication notes or collaboration notes that are done between the Dialysis Center and the Facility on the days Resident #17 goes to Dialysis? She replied, Here is the resident's binder for the Dialysis. The Surveyor looked in the binder and there were only 2 documents in the binder, the Face Sheet for admission to the Nursing Facility and Resident #17's Code Status Form documenting that the resident was a full code. No other information was in the file. The Surveyor asked, Is this all that is here? She stated, Well that is just her Face Sheet and code status information, it has nothing else, that does not help at all. d. On 04/06/23 at 3:00 PM., the Surveyor asked the DON for the communication notes used between the Dialysis Center and the Facility for Resident #17. The DON replied, We don't have any communication notes, I don't know what they are doing, we use to get those dialysis cards after the treatments. Those forms in the binder for her dialysis are not even the forms we would use; I don't know why they are even in there. I don't see the lab information in the EHR from the Dialysis Center, but I can get them for you. e. On 04/06/23 at 3:15 PM., the Surveyor asked the Activities Director/Transport Certified Nurse's Assistant, When a resident is taken to and from Dialysis Center, do you receive any documentation from the center regarding how the resident tolerated Dialysis for that day or care card reports? She stated, No, I take her in the front lobby and then they take her back and when I go back to get her, they have her out in the lobby ready to go and they don't give me anything. f. On 04/06/23 at 4:10 PM., a copy of Guidance titled Dialysis 42 C.F.R. 483.25(I) provided to the Surveyor stated, .The Nursing Facility will consult Lippincott Nursing Manual, 2014 10th [tenth] edition as the guide for matters relating to the provision of Dialysis services and follow Physician's Orders . The DON stated, We don't have a policy, we use the Lippincott Nursing Manual as a guide. g. On 04/07/23 at 8:45 AM., the Surveyor asked the Administrator, Who is responsible for the lab results communication and daily dialysis collaboration notes for the dialysis residents? The Administrator stated, That is going to be our new Assistant Director of Nursing we have hired. The Surveyor asked, If the Dialysis Center and the facility does not have ongoing communication and collaboration with each other, how could that affect the resident? The ADON stated, Well it is not the best interest of the resident, and their care.

Based on Observation, Interview and Record Review the facility failed to place signage on a resident's entry way to identify the use of Oxygen by the resident, for 1 (#226) of 6 (#11, #15, #33, #57, #63 and #226) sampled residents who received Supplemental Oxygen. The findings are: 1.Resident #226 had diagnoses of Malignant Neoplasm of transverse Colon, Malignant Neoplasm of Right Lung, and Malignant Neoplasm of Left Lung. The Admission Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/23 documented a Brief Interview for Mental Status (BIMS) of 15 (13-15 cognitively intact), required one person assist with bathing, personal hygiene, dressing, supervision with setup only for bed mobility, transfers, walk in room and corridors, locomotion on and off unit, eating and toilet use, and received supplemental oxygen. a. The Physician's Order dated 03/18/23 documented, .Oxygen at 2 Liters Per Milliliter [LPM] via nasal cannula as needed every shift b. The Physician's Order dated 03/19/23 documented, .Change all disposable respiratory equipment and clean/replace filters every night shift every Sun [Sunday] . c. The Care Plan dated 03/20/23 documented, .Administer Oxygen as needed at 2 liters per nasal canula . Licensed Practical Nurse (LPN) to change all disposable respiratory equipment and clean/replace filter every Sunday night shift . d. On 04/03/23 at 10:34 AM., Resident #226 was sitting on the side of his bed with the Nasal Canula connected to an Oxygen Concentrator that was not running. He asked the Surveyor, Would you turn on my oxygen? It should be at 2 liters. The concentrator was not running but power switch was in the on position. The Treatment Nurse was notified, and she was able to switch the plug that the concentrator was connected to, and it powered on. There was no signage on his door or doorway indicating that Oxygen was in use and the precautions to follow on 04/04/23, 04/05/23, or 04/06/23. e. On 04/06/23 at 3:45 PM., the Surveyor asked LPN #1, Who is responsible for setting up the resident's room for a resident who requires Supplemental Oxygen? LPN #1 responded, The nurse. The Surveyor asked, What precautions are needed for a resident who requires Oxygen and how do you indicate that? LPN #1 stated, They need a No Smoking sign, Oxygen in Use Sign. The Surveyor asked, Who is responsible to make sure an Oxygen sign is in place? LPN #1 stated, All of us nurses. The Surveyor asked, What could happen if an Oxygen in use sign is not in place? LPN #1 stated, They could try to smoke and blow up. Someone could light a match. f. On 04/06/23 at 3:50 PM., the Surveyor asked the Director of Nursing (DON), Who is responsible for preparing a resident's room for Oxygen use? The DON stated, The nurses, usually the Admission Nurse, but we all do it. The Surveyor asked, What precautions are needed if oxygen is used in an area? The DON stated, The area the oxygen is stored in is identified with a sign, a no smoking sign, if it's in cylinders they have to be secured so they don't tip over, has be stored off the ground. The Surveyor asked, What could happen if the precautions weren't in place? The DON stated, Someone could cause it to explode. The DON came to the Surveyor at 4:15 PM and stated, This is a Non-Smoking Facility, there are signs for no smoking at the front entrance and one going out the smoking area that indicates no Oxygen use. g. The facility policy titled, Procedure Guidelines for Administering Oxygen by Nasal Cannula, provided by the DON on 04/06/23 at 4:40 PM documented, .Post NO SMOKING signs on the patient's door and in view of the patient and visitors .

Based on record review and interview the facility failed to convey within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law, upon the death of 2 Residents (#125 and #126) who had personal funds deposited with the facility. The findings are: The Review of the Trust Account Documentation provided by the Business Office Manager (BOM) on 04/04/23 at 3:00 pm revealed that Resident #125 had a trust balance of $1723.61 and Resident #126 had a trust balance of $224.13. The Record Review completed on 04/04/23 at 3:30pm revealed that Resident #125 was admitted to the facility on [DATE]. She had a Durable Power of Attorney signed and notarized on 07/23/20 on file with the facility. A document titled Record of Death stated that her date of death was 10/02/22. The Record Review completed on 04/04/23 at 3:45pm revealed that Resident #126 was admitted to the facility on [DATE]. She had a [family member] who was the responsible party during her stay at the facility. She was admitted to the hospital on 02/10/22. On 02/21/22 at 13:25 [1:25] stated that the hospital notified the facility of her death. The Progress Note completed by the Social Services Director on 03/08/22 at 10:58am stated that her [family member] (responsible party) notified the facility and directed Social Services to contact her [family member] and arranged for her belongings to be picked up . On 04/05/23 at 8:45am., the Surveyor asked the BOM, How long should the facility keep a resident's funds in a trust account after the resident has discharged from the facility? The BOM stated, It should be refunded within 30 days. The Surveyor asked, Can you tell me why Resident #125 and Resident #126 have funds in a trust account? The BOM stated, I was told there is not a beneficiary on file. The Surveyor asked, If a resident has a responsible party or a durable power of attorney should they receive the funds left in the trust account when a resident passes away? The BOM stated, Yes.

Based on observation, interview, and record review the facility failed to ensure pressure ulcers were treated according to Physician Orders. This failed practice had the potential to affect 1 (Resident #1) of 3 (#1, #2, #3) case mix residents. The findings are: 1. Resident #1 had diagnoses of Quadriplegia and Pressure Ulcer of Sacral Region. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive to total assistance with Activity of Daily Living (ADL)s, and had 3 Unhealed Stage 4 Pressure Ulcers. a. The Physician's Order with a revision date of 03/05/23 documented, .Coccyx: Cleanse with wound cleanser/pat dry. Apply Collagen to wound bed followed by Calcium Alginate. Cover with dry absorbent dressing. Change MWF [Monday, Wednesday, Friday] and PRN for soiling/saturation. Every 8 hours as needed for wound care . b. The Wound Care Orders dated 03/16/23 and scanned into Resident #1's Electronic Medical Record (EMR) titled, Heartland Rehabilitation and Care Center, documented in the upper left-hand corner, .fill out and send back with Resident . It further documented, . [Resident #1] Was seen on 03/16/23 . D/C [discontinue] wound vac [vacuum]. Cleanse with NS [normal saline] or wound cleanser, pat dry. R [right] and L [left] ischium: Apply Dakins wet to dry dressing and change daily and PRN Coccyx: Apply Prisma moistened with saline, cover with Silvercel and change 3xwk [3 times a week] [and] PRN [as needed]. Cover all with c [with] dry drsg [dressing] silicone foam border or gauze and tape . and was signed by a practitioner. c. The Wound Care Nurse Note with a revision date of 03/17/23 documented, .Returned from [Wound Care Clinic] Orders to discontinue wound vac therapy. Continue with current orders to coccyx. New orders to Right and Left Ischium: Cleanse with wound cleanser. Pat dry. Apply (Dakin's moistened gauze to wound bed. Cover with silicone foam or gauze and tape. Change Daily and PRN for soiling/saturation. Cover all wound with silicone foam or gauze and tape per Wound clinic APRN [Advanced Practice Registered Nurse] . d. The Wound Care Nurses Note with an effective date of 03/28/23 documented, .Order corrected to follow [Wound Clinic] order to Coccyx: Cleanse with wound cleanser/pat dry. Apply Collagen to wound bed followed by Calcium Alginate with silver. Cover with dry absorbent dressing. Change M/W/F and PRN for soiling/saturation . and was signed by LPN #1. e. On 03/28/23 at 8:35am., Resident #1 was sitting in her bed at a 45-degree angle. She was on a low air loss mattress. The Surveyor asked if she had wounds. She stated, Yes, on my bottom. The Surveyor asked if she was being turned every 2 hours. She stated, I can't turn myself, so the staff come and reposition me. f. On 03/28/23 at 1:40pm., the Surveyor asked Licensed Practical Nurse (LPN) #1 if she had any knowledge of the Physician Orders not being followed, or the wounds not being documented with the intent of seeing if they can be healed first. LPN #1 stated, No, if a wound is found it is documented and the Advanced Practical Nurse (APN) is notified. She sees them weekly, and anything treated has to be documented. The Surveyor asked if any orders are written and signed by staff claiming to be a Physician. LPN #1 stated, No. Every Wednesday we do visits using telehealth. We facetime and she looks at all the wounds. She determines the treatment and sends me a secure message with either no changes or new orders then I put the orders in the computer, and she signs off on them. She is also able to send messages to other providers if something medically is a contributing factor and needs addressed by the Primary Care Physician like edema. g. On 03/28/23 at 3:38pm., the Surveyor reviewed the Wound Clinic visit orders for Resident #1's coccyx with LPN #1 and as the Surveyor was reading the orders, LPN #1 stated, Prism is collagen. The Surveyor responded, Yes, I am aware. LPN #1 stated, I usually look things up on [search engine] if they are unfamiliar so I will know what can be used in their place. The Surveyor continued to read the orders and asked LPN #1 what Silvercel was referring to. LPN #1 stated, Calcium Alginate. The Surveyor stated, Yes but with silver, right? LPN #1 replied, Yes. The Surveyor asked LPN #1 to review the order in the EMR dated 03/05/23 and if the order for Calcium Alginate contained the use of silver and its antimicrobial properties. LPN #1 reviewed the order and stated, No. It doesn't. I guess I messed up. That wound is almost healed though. Do you want to see it? The Surveyor agreed and accompanied LPN #1 to the treatment cart. LPN #1 pushed the cart down to the room and parked it outside Resident #1's room. LPN #1 performed hand hygiene and prepared the following supplies: [Extra II wound dressing] 2x(by)2-inch, collagen 2x2 inch, a bordered 4x4 inch foam dressing, 4x4 inch gauze in a cup and sprayed it with wound cleanser. LPN #1 requested a Certified Nursing Assistant (CNA) to assist with turning her for wound care. We entered the room, and she explained the purpose to her. When Resident #1's back side was exposed, there was a dressing shaped like an upside-down U that consisted of ABD [abdominal] pads and paper tape covering both ischiums and the coccyx. LPN #1 stated, This is just on her because her catheter was leaking this morning and they had to change it. LPN #1 pulled the secondary dressing off and there were 2x2 inch gauzes on the left and right ischial wounds. The coccyx wound did not have collagen or Calcium Alginate covering the wound under the ABD pad. The coccyx wound was approximately 1.5cm [centimeters] x 1cm x 0.3cm in size. The wound bed was pink. The wound edges peri-wound were white. LPN #1 cleansed the coccyx wound with 4x4's soaked with wound cleanser, applied the 2x2 inch square of collagen over the wound, placed the 2x2 inch Calcium Alginate [Extra II wound dressing] over the collagen, and placed the 4x4 inch bordered foam dressing securing it to the skin. She then told the CNA she would have to get additional supplies from her cart outside the door to replace the other dressings. The Surveyor left the room. h. On 03/29/23 at 8:45am., LPN #1 provided a document dated 03/21/23 titled Packing Slip and stated, I thought you might want this. [Medical Equipment Supply Company] provided the supplies for [Resident #1] and it shows that they have been sending silver Calcium Alginate for her wound care. The Surveyor stated, But your order in the computer that you are going by states Calcium Alginate and when I watched you provide wound care you put [Extra II wound dressing] on the wound which does not contain silver. LPN #1 stated, Yeah, that was my mistake. That's on me. The Surveyor looked at the packing slip and asked LPN #1, When did you receive these supplies? LPN #1 replied, The date is on it, whatever it says. The Surveyor asked, Where were these supplies yesterday when wound care was provided? LPN #1 stated, In a box in the floor of my office unopened. i. On 03/30/23 at 10:35am., the Surveyor asked the Director of Nursing (DON) to look at the Physician's Order dated 03/05/23 in the EMR and was asked if Calcium Alginate contains silver. The DON stated, No, not if it is just Calcium Alginate. The Surveyor asked the DON to look at the Wound Clinic Orders from 03/16/23 and then asked if the wound care orders for Resident #1's coccyx contained silver. He stated, Yes, Silvercel. The Surveyor asked if this order should have been updated when the order was received. The DON stated, Yes, or if it was a supply issue, then it should have been clarified until supplies were available. The Surveyor asked the DON what are the properties that silver adds to the treatment. The DON stated, Antimicrobial. j. The facility policy titled, Dressing Change Guidelines, provided by the DON on 03/30/23 at 10:00am documented, .Confirm the most recent treatment order .Check TARS (Treatment Administration Record) and check chart .

Based on record review and interview, the facility failed to ensure a fracture of unknown origin, with a subsequent allegation of possible staff-to-resident abuse or neglect, was thoroughly investigated to facilitate the ability to put appropriate protective measures in place to prevent further potential injury or abuse for 1 (Resident #2) of 1 resident who was cognitively impaired and had a serious injury of unknown origin. The findings are: Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set with an Assessment Reference Date of 10/14/21 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status; required extensive one-person physical assistance with bed mobility, locomotion on and off the unit, dressing and toilet use; required extensive two-plus persons physical assistance with transfers; was totally dependent on 2-plus persons for bathing; and had functional limitation in range of motion to the upper and lower extremity on one side. a. An Office of Long Term Care (OLTC) Incident and Accident Report dated 12/14/21 documented, Date and Time Submitted . 12/14/2021 10:45 a.m . Summary of Incident: Injury of unknown origin. On 12/13/21 at approx. [approximately] 10:32 p.m., the Administrator was notified immediately that [Resident #2] had an x-ray on her upper left arm and it was indicated that there is a fracture of the humeral neck of left arm. At approx. 10:00 a.m. on 12/13/21, APN [Advanced Practice Nurse] assessed [Resident #2] due to resident voicing to her charge nurse having pain in her left shoulder area. APN, after evaluating resident, ordered x-rays as an intervention. Radiology report received by the facility indicates as follows: There is a fracture of the humeral neck . sft [soft] tissue swelling is seen . fracture of the humeral neck of uncertain age . [Resident #2] was interviewed last night (12/13/21) and asked what happened. Resident stated to charge nurse that she has not fallen or had any accidents lately, and she hasn't bumped into anything per questions asked by the charge nurse . Resident's daughter was called to notify of the situation. Nurse notified daughter that resident did not have any idea how the fracture may have occurred . daughter alleged that her mom [Resident #2] had told her 'a while back' that [Resident #2] had alleged to her that someone assisting her with getting a shower had twisted her arm while helping her . A prior x-ray report dated 12/17/2020 indicates that resident had osteopenic bones at the time of that report . Investigation is under way. Staff will be interviewed, and witness statements will be taken . Findings and Actions Taken: .Witness statements completed by staff members on various shifts . There was no documentation to indicate any other residents were interviewed as to their knowledge of how the resident's injury may have occurred or as to whether they were aware of any rough handling by staff. There was no documentation to indicate body audits were conducted to rule out other injuries or that staff were observed conducting resident transfers and showers to determine if they were performed safely and correctly. b. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Sling to left arm every shift for Left Humeral Fracture . c. A typed statement dated 12/16/21 by the Orthopedic Surgeon documented, .[Resident #2] . Was seen in the office on 12/15/2021 . hair line fracture in shoulder should heal on its on [own] in 4 weeks as long as it is protective [sic] properly with the sling and little mobility. The patient is unsure how this injury had occurred, so it would be impossible to say how it happened . d. On 01/13/22 at 2:48 p.m., Licensed Practical Nurse (LPN) #1 was asked, [Resident #2's] daughter alleged that the resident reported someone had twisted her arm during a shower. Did you interview the resident or other residents about this allegation? She stated, I can't recall. She was asked, Who is responsible for investigating allegations of abuse? She stated, Well we all are, but the Director of Nursing and Administrator are responsible for reporting the abuse. She was asked what should be done if a family member alleges possible abuse. She stated, Notify the DON. She was asked, How soon would you report it? She stated, Soon as possible. She was asked if cognitively intact residents should be interviewed about the allegation of abuse and, if so, when. She stated, Yes, I guess they should be interviewed right then. e. On 01/13/22 at 3:30 p.m., the Administrator stated, The last Administrator started that investigation. When he quit, I had to finish the investigation. It's a team effort to complete the investigation. I believe the charge nurse interviewed the resident. I interviewed the cognitive residents. She was asked, Where are the resident interviews documented or located? She stated, I gave them to the [former] Administrator. I was not in this position at the time the incident occurred. She was informed that no resident interviews were documented or attached to the previously provided facility abuse investigation and was asked where documentation of those interviews was located at this time. She stated, I'll have to go look in my office. The surveyor accompanied the Administrator to her office. f. On 01/13/22 at 3:40 p.m., the Administrator was asked, Have you located the resident interviews? She stated, Not at this time. She was asked if cognitively intact residents should be interviewed regarding allegations of staff-to-resident abuse and, if so, when. She stated, Immediately. g. On 01/13/22 at 4:30 p.m. the Administrator was asked, Did you find the resident interviews? She stated, No, ma'am. She was asked if documentation of an abuse investigation should be readily available for review and stated, Yes. h. On 01/14/22 at 11:52 a.m., the Administrator entered the conference room and handed the surveyor 5 crumpled sheets of paper, which were OLTC Witness Statements. She was asked, Where did you find the resident Witness Statements? She stated, I found them crumpled up in a drawer. i. On 01/14/22 at 12:19 p.m., the Administrator was asked if body audits / skin assessments were conducted on other residents after the allegation of possible abuse / neglect for Resident #2. She stated, I'm not sure. I'll have to check with the DON. j. On 01/14/21 at 1:40 p.m., the DON was asked, Was a body audit conducted on [Resident #2] and other residents? She stated, It was not a skin issue. k. The facility's Abuse, Neglect, and Maltreatment Investigation & Reporting Policy and Procedure documented, .Identification and investigation of abuse, neglect .should include interviews with those persons the investigator determines should have knowledge of events related to allegation or incident. The investigator should consider interviewing persons listed below: .ii. Resident / Elder .iv. Other Residents / Elders .

Based on record review and interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, as evidenced by failure to ensure Cardiopulmonary Resuscitation (CPR) was provided for 1 (Resident #76) of 1 sampled resident who was found without vital signs and had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #76, who was found unresponsive and without vital signs, did not receive CPR from facility staff, and subsequently expired, and the potential to cause more than minimal harm to 34 residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator was informed of the Immediate Jeopardy condition on [DATE] at 5:20 PM. The facility also failed to ensure code status was consistently documented in an easily accessible area of the clinical record to enable staff to quickly ascertain a resident's code status in the event of an emergency for 1 (Resident #2) of 6 (Residents #49, #16, #55, #32, #2, and #18) sampled residents whose Advance Directive and code status information was reviewed. The findings are: 1. Resident #76 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 5 (,d+[DATE] indicates severely cognitively impaired) on a Brief Interview for Mental Status and required extensive physical assistance of 1 person for bed mobility, personal hygiene and toilet use and extensive physical assistance of 2 plus persons with transfers. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Full Code . b. The Care Plan dated as initiated [DATE] documented, .I have requested that CPR measures be performed. I am a Full Code. c. An Admission Progress Note dated [DATE] at 1:40 PM documented, .Admission Summary Note Text: admitted to facility for Skilled Care and Services . Resident admitted from hospital . was transported to facility by vehicle entering the facility via wheelchair accompanied by facility staff, Code Status: Full Code . d. A Progress Note dated [DATE] at 11:08 AM documented, . Summary of care provided: Denies pain or discomfort. No s/s [signs and symptoms] of acute distress noted . Resident's level of consciousness is Alert. Resident is oriented to person. Resident has no cognition impairment . Resident has no changes. Resident has no signs or symptoms of a swallowing disorder . e. A Progress Note dated [DATE] at 1:06 AM documented, .Summary of care provided: received in bed with eyes open a little restless. Respiration even unlabored. Fluids running per cylices and tolerating well, incontinent of B&B [bowel and bladder] with peri care as needed via nursing staff. Side rails up call light within easy reach fluids at bedside . The resident does not have pain . f. A Progress Note dated [DATE] at 9:25 AM documented, .Nursing Note Late Entry: Note Text: late entry . At approximately 0333 [3:33 AM] the CNA [Certified Nursing Assistant] reported to me that he observed [resident] in his bed not breathing, we went directly to the resident's room. I found the resident laying on the bed in the supine position, his mouth was open, arms at his side, without respirations, without a pulse, cool to the touch, pale in appearance. I immediately called 911, the APN [Advanced Practice Nurse], the coroner and the son. EMT [Emergency Medical Technician] arrived at 0345 [3:45 AM], the coroner arrived at 0430 [4:30 AM] and pronounced at 0434 [4:34 AM] . There was no documentation to indicate CPR was initiated. There was no documentation the resident's pupils were checked, that the carotid pulse, respirations and lung sounds were auscultated (and absent) for at least 30 seconds, or that dependent lividity or rigor were present. g. On [DATE] at 1:55 PM, the Director of Nursing (DON) was asked, Did the resident have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She said, Yes. The DON was asked, based on the Progress Notes, He was seen at 1:06 AM with no concerns. He was found later at 0333 [3:33 AM] by a CNA in bed not breathing. Should CPR have been started? She said, I was here that night. He was found unresponsive, cold to touch and mottling. The DON was asked, Can you tell me where that is documented? She said, I documented his arms were at his sides. When the coroner arrived, I asked him should I have started CPR. The DON was asked, Did you follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She said, No, I guess not. 2. Resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan with a revision date of [DATE] documented, .[Resident #2] have requested that no CPR measures be performed. My code status is DNR . b. On [DATE] at 8:17 PM, Resident #16's electronic health record (EHR) documented a new order for Hospice dated [DATE]. A Do Not Resuscitate (DNR) order dated [DATE] was signed by the physician and scanned into Resident #2's EHR on [DATE]. There was no code status on Resident #2's care profile in the EHR or on the Order Summary Report dated [DATE]. c. On [DATE] at 3:30 PM, the DON was asked to look in Resident #2's EHR for the resident's code status. The DON looked at the care profile (face sheet) in the EHR and stated, Well, just looking at this I would say she is probably a DNR since she is being admitted to Hospice. The DON was asked if she could determine by looking at the resident's electronic face sheet that the resident was a DNR. She said, Well, no not just by opening it up and looking at it. She was asked, So, if you were walking by the resident's room and the resident was not breathing, would you know to provide CPR or not by looking at her electronic face sheet? She stated No. 3. On [DATE] at 1:59 PM, Licensed Practical Nurse (LPN) #1 was asked, What is the protocol for not starting CPR? She stated, If the resident is DNR [Do Not Resuscitate]. She was asked how she would know the code status and she stated, It is in their chart. She was asked, If a resident is a Full Code and they aren't breathing when you walk into their room, why would you not do CPR? She stated, They are DNR. 4. On [DATE] at 2:00 PM, Registered Nurse (RN) #1 was asked, What is the protocol for not starting CPR? She said, If the resident has a pulse and is a DNR, you have the code status and the vital signs to go by. She was asked, If the resident is a Full Code and they are not breathing when you walk the room, when would you not perform CPR? She replied, If they have a pulse do not do the chest compression, but if they don't have a pulse then start CPR and do the whole 9 yards. 5. On [DATE] at 2:02 PM, LPN #3 was asked, If a resident is a full code and not breathing when you walk into a room, when would you not do CPR? She said, You would always do CPR, they made that determination, best practice. LPN #3 was asked, How have you been trained when to do or not to do CPR? She said, I've taken classes. If I saw someone in the woods not breathing, I would do CPR, instinct. Here in the facility, if they are DNR we do not do CPR, if they are full code, we do CPR. 6. On [DATE] at 2:10 PM, LPN #2 was asked, What is the protocol for not starting CPR? He replied, If resident is a DNR. He was asked, If a resident is a full code and is not breathing, when would you not start CPR? He replied, If they are not a DNR, start CPR. 7. On [DATE] at 4:59 PM, LPN #1 was asked, If you walked into resident's room and they were not breathing, how do you know their code status? She stated, I would look in their chart. She was asked, Where in the chart would you look? She stated, On the face sheet, it tells their code status. LPN #1 was asked if she would show this surveyor where to look in the chart. LPN #1 went into the chart and pointed out the code status on the electronic face sheet. LPN #1 was asked if the code status was documented in every resident's chart and stated, It is supposed to be, but it if isn't, I would look in the documents. She was asked how long it would take her to find it like that. She stated, Too long. It is also listed over here in this Status Book. LPN #1 and walked over to the 400 Hall Nurse's Station and LPN #1 looked for the Status Book and stated, Well it isn't here, I don't know where it is. 8. Arkansas Act 718 of 2009, [DATE], Withholding cardiopulmonary resuscitation in nursing facilities for unwitnessed deaths documented, As used in this section . dependent lividity means clear demarcation of pooled blood within the body . Rigor means that major joints such as the jaw, shoulders, elbows, hips or knees are immovable . Licensed Nurses employed by nursing facilities may withhold cardiopulmonary resuscitation from residents of the facility, regardless of the presence or absence of a Do Not Resuscitate Order when: 1) The death of the resident was unwitnessed; and 2) The body evidences clear and unmistakable: A) Dependent lividity; or B) Rigor. (c) In cases of unwitnessed deaths under subsection (b) of this section, the following conditions also must be present: (1) Respirations are absent for at least (30) seconds; (2) Carotid pulse is absent for at least (30) seconds; (3) Lung sounds auscultated by stethoscope bilaterally are absent for at least thirty (30) seconds; and (4) Both pupils, if accessible, are nonreactive to light. (d) The nursing facility shall document the presence of the above-listed conditions in the resident's records . 9. The Immediate Jeopardy was removed, and the scope and severity reduced to G on [DATE] when the facility implemented the following Plan of Removal: 1. On [DATE], Nurse Consultant trained Administrator and DON on Arkansas Law for withholding CPR. 2. On [DATE], the ADON/Designee will review code status of all residents to verify accuracy in electronic records forms. 3. On [DATE], the DON/Designee has identified all residents code status and the IDT [Interdisciplinary Team] Team has verified that Code Status matches physicians order and is displayed in the header of the Resident's chart. 4. On [DATE], in-service was started with nurses currently on duty and ongoing training will be performed with all active nursing employees prior to working their next scheduled shift. DON/Designee directed staff to initiate CPR when cardiac or respiratory arrest occurs for residents who do not show obvious clinical signs of irreversible death; (1) Respirations are absent for at least thirty seconds; (2) Carotid pulse is absent for at least (30) seconds; (3) Lung sounds auscultated by stethoscope bilaterally are absent for at least thirty (30) seconds. (4) Both pupils, if accessible, are nonreactive to light. 'Dependent Lividity' means clear demarcation of pooled blood within the body 'Rigor' means major joints such as jaw, shoulders, elbows, hips, or knees are immovable. Nurses will be trained on how to document those items for any full code resident who expires in the facility. 5. Starting [DATE], during daily startup, any code status changes will be reviewed by the IDT and charts, care plans & [and] physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any negative findings will be corrected upon discovery and reported to QA [Quality Assurance] Committee for review and recommendations. Any further resident deaths will be reviewed to ensure staff responded and documented appropriately.

Based on record review and interview, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was provided for 1 (Resident #76) of 1 sampled resident who was found without vital signs and had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #76, who was found unresponsive and without vital signs, did not receive CPR from facility staff, and subsequently expired, and the potential to cause more than minimal harm to 34 residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator was informed of the Immediate Jeopardy condition on [DATE] at 5:20 PM. The facility also failed to ensure code status was consistently documented in an easily accessible area of the clinical record to enable staff to quickly ascertain a resident's code status in the event of an emergency for 1 (Resident #2) of 6 (Residents #49, #16, #55, #32, #2, and #18) sampled residents whose Advance Directive and code status information was reviewed. The findings are: 1. Resident #76 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 5 (,d+[DATE] indicates severely cognitively impaired) on a Brief Interview for Mental Status and required extensive physical assistance of 1 person for bed mobility, personal hygiene and toilet use and extensive physical assistance of 2 plus persons with transfers. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Full Code . b. The Care Plan dated as initiated [DATE] documented, .I have requested that CPR measures be performed. I am a Full Code. c. An Admission Progress Note dated [DATE] at 1:40 PM documented, .Admission Summary Note Text: admitted to facility for Skilled Care and Services . Resident admitted from hospital . was transported to facility by vehicle entering the facility via wheelchair accompanied by facility staff, Code Status: Full Code . d. A Progress Note dated [DATE] at 11:08 AM documented, . Summary of care provided: Denies pain or discomfort. No s/s [signs and symptoms] of acute distress noted . Resident's level of consciousness is Alert. Resident is oriented to person. Resident has no cognition impairment . Resident has no changes. Resident has no signs or symptoms of a swallowing disorder . e. A Progress Note dated [DATE] at 1:06 AM documented, .Summary of care provided: received in bed with eyes open a little restless. Respiration even unlabored. Fluids running per cylices and tolerating well, incontinent of B&B [bowel and bladder] with peri care as needed via nursing staff. Side rails up call light within easy reach fluids at bedside . The resident does not have pain . f. A Progress Note dated [DATE] at 9:25 AM documented, .Nursing Note Late Entry: Note Text: late entry . At approximately 0333 [3:33 AM] the CNA [Certified Nursing Assistant] reported to me that he observed [resident] in his bed not breathing, we went directly to the resident's room. I found the resident laying on the bed in the supine position, his mouth was open, arms at his side, without respirations, without a pulse, cool to the touch, pale in appearance. I immediately called 911, the APN [Advanced Practice Nurse], the coroner and the son. EMT [Emergency Medical Technician] arrived at 0345 [3:45 AM], the coroner arrived at 0430 [4:30 AM] and pronounced at 0434 [4:34 AM] . There was no documentation to indicate CPR was initiated. There was no documentation the resident's pupils were checked, that the carotid pulse, respirations and lung sounds were auscultated (and absent) for at least 30 seconds, or that dependent lividity or rigor were present. g. On [DATE] at 1:55 PM, the Director of Nursing (DON) was asked, Did the resident have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She said, Yes. The DON was asked, based on the Progress Notes, He was seen at 1:06 AM with no concerns. He was found later at 0333 [3:33 AM] by a CNA in bed not breathing. Should CPR have been started? She said, I was here that night. He was found unresponsive, cold to touch and mottling. The DON was asked, Can you tell me where that is documented? She said, I documented his arms were at his sides. When the coroner arrived, I asked him should I have started CPR. The DON was asked, Did you follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She said, No, I guess not. 2. Resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan with a revision date of [DATE] documented, . [Resident #2] have requested that no CPR measures be performed. My code status is DNR . b. On [DATE] at 8:17 PM, Resident #16's electronic health record (EHR) documented a new order for Hospice dated [DATE]. A Do Not Resuscitate (DNR) order dated [DATE] was signed by the physician and scanned into Resident #2's EHR on [DATE]. There was no code status on Resident #2's care profile in the EHR or on the Order Summary Report dated [DATE]. c. On [DATE] at 3:30 PM, the DON was asked to look in Resident #2's EHR for the resident's code status. The DON looked at the care profile (face sheet) in the EHR and stated, Well, just looking at this I would say she is probably a DNR since she is being admitted to Hospice. The DON was asked if she could determine by looking at the resident's electronic face sheet that the resident was a DNR. She said, Well, no not just by opening it up and looking at it. She was asked, So, if you were walking by the resident's room and the resident was not breathing, would you know to provide CPR or not by looking at her electronic face sheet? She stated No. 3. On [DATE] at 1:59 PM, Licensed Practical Nurse (LPN) #1 was asked, What is the protocol for not starting CPR? She stated, If the resident is DNR [Do Not Resuscitate]. She was asked how she would know the code status and she stated, It is in their chart. She was asked, If a resident is a Full Code and they aren't breathing when you walk into their room, why would you not do CPR? She stated, They are DNR. 4. On [DATE] at 2:00 PM, Registered Nurse (RN) #1 was asked, What is the protocol for not starting CPR? She said, If the resident has a pulse and is a DNR, you have the code status and the vital signs to go by. She was asked, If the resident is a Full Code and they are not breathing when you walk the room, when would you not perform CPR? She replied, If they have a pulse do not do the chest compression, but if they don't have a pulse then start CPR and do the whole 9 yards. 5. On [DATE] at 2:02 PM, LPN #3 was asked, If a resident is a full code and not breathing when you walk into a room, when would you not do CPR? She said, You would always do CPR, they made that determination, best practice. LPN #3 was asked, How have you been trained when to do or not to do CPR? She said, I've taken classes. If I saw someone in the woods not breathing, I would do CPR, instinct. Here in the facility, if they are DNR we do not do CPR, if they are full code, we do CPR. 6. On [DATE] at 2:10 PM, LPN #2 was asked, What is the protocol for not starting CPR? He replied, If resident is a DNR. He was asked, If a resident is a full code and is not breathing, when would you not start CPR? He replied, If they are not a DNR, start CPR. 7. On [DATE] at 4:59 PM, LPN #1 was asked, If you walked into resident's room and they were not breathing, how do you know their code status? She stated, I would look in their chart. She was asked, Where in the chart would you look? She stated, On the face sheet, it tells their code status. LPN #1 was asked if she would show this surveyor where to look in the chart. LPN #1 went into the chart and pointed out the code status on the electronic face sheet. LPN #1 was asked if the code status was documented in every resident's chart and stated, It is supposed to be, but it if isn't, I would look in the documents. She was asked how long it would take her to find it like that. She stated, Too long. It is also listed over here in this Status Book. LPN #1 and walked over to the 400 Hall Nurse's Station and LPN #1 looked for the Status Book and stated, Well it isn't here, I don't know where it is. 8. Arkansas Act 718 of 2009, [DATE], Withholding cardiopulmonary resuscitation in nursing facilities for unwitnessed deaths documented, As used in this section . dependent lividity means clear demarcation of pooled blood within the body . Rigor means that major joints such as the jaw, shoulders, elbows, hips or knees are immovable . Licensed Nurses employed by nursing facilities may withhold cardiopulmonary resuscitation from residents of the facility, regardless of the presence or absence of a Do Not Resuscitate Order when: 1) The death of the resident was unwitnessed; and 2) The body evidences clear and unmistakable: A) Dependent lividity; or B) Rigor. (c) In cases of unwitnessed deaths under subsection (b) of this section, the following conditions also must be present: (1) Respirations are absent for at least (30) seconds; (2) Carotid pulse is absent for at least (30) seconds; (3) Lung sounds auscultated by stethoscope bilaterally are absent for at least thirty (30) seconds; and (4) Both pupils, if accessible, are nonreactive to light. (d) The nursing facility shall document the presence of the above-listed conditions in the resident's records . 9. The Immediate Jeopardy was removed, and the scope and severity reduced to G on [DATE] when the facility implemented the following Plan of Removal: 1. On [DATE], Nurse Consultant trained Administrator and DON on Arkansas Law for withholding CPR. 2. On [DATE], the ADON/Designee will review code status of all residents to verify accuracy in electronic records forms. 3. On [DATE], the DON/Designee has identified all residents code status and the IDT [Interdisciplinary Team] Team has verified that Code Status matches physicians order and is displayed in the header of the Resident's chart. 4. On [DATE], in-service was started with nurses currently on duty and ongoing training will be performed with all active nursing employees prior to working their next scheduled shift. DON/Designee directed staff to initiate CPR when cardiac or respiratory arrest occurs for residents who do not show obvious clinical signs of irreversible death; (1) Respirations are absent for at least thirty seconds; (2) Carotid pulse is absent for at least (30) seconds; (3) Lung sounds auscultated by stethoscope bilaterally are absent for at least thirty (30) seconds. (4) Both pupils, if accessible, are nonreactive to light. 'Dependent Lividity' means clear demarcation of pooled blood within the body 'Rigor' means major joints such as jaw, shoulders, elbows, hips, or knees are immovable. Nurses will be trained on how to document those items for any full code resident who expires in the facility. 5. Starting [DATE], during daily startup, any code status changes will be reviewed by the IDT and charts, care plans & [and] physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any negative findings will be corrected upon discovery and reported to QA [Quality Assurance] Committee for review and recommendations. Any further resident deaths will be reviewed to ensure staff responded and documented appropriately.

Based on observation, record review and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items; kitchen equipment was maintained in clean condition; food items were stored covered, sealed, labeled, and dated; and dented cans were removed from stock to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The findings are: 1. On 12/06/21 at 9:54 AM, during the initial rounds of the kitchen with Dietary Employee (DE) #1, the following observations were made in the dry storage area: a. There was sugar, corn meal and flour in unsealed, thin, black, plastic bags that were stored in storage bins with no lids. DE #1 was asked, Why are the lids in the bins and not covering the containers? She said, The lids are broken. b. There was a tray of buns sitting on the floor. DE #1 was asked, Should they be stored on the floor? She said, No, they were sitting up there on the tray earlier. c. A dented can of grape jelly, a dented can of fruit salad and 2 dented cans of cherry pie filling were stored on a shelf with other non-dented canned goods. DE #1 was asked, Should you have dented cans on the shelf? She said, No. d. There was a bag of grits that was not sealed and dated. DE #1 was asked, Should that be sealed? She said, Yes. 2. On 12/06/21 at 10:07 AM, the following observations were made in the refrigerator and freezer: a. In the refrigerator, there were 5 cantaloupes with a green furry substance on the outer area of them. DE #1 was asked, Does that look like mold to you? She said, Yes, they are old. b. An opened package of sliced ham was not sealed or dated. c. In the freezer, a bag of hushpuppies had been left open to air. DE#1 was asked, Should it be sealed and dated? She said, Yes, they used it Friday [12/03/21]. 3. On 12/06/21 at 10:13 AM, the commercial grade can opener had a thick black substance on the blade. DE #1 was asked, Can you tell me what is on the blade? She said, It is crud, we have a new one, but it is too small. We can't get that one clean. The condiments storage container had a brown substance built up on the container and spilled sugar in the bottom of the container. DE#1 was asked, Does the container need to be cleaned? She said, Yes. The steam table had a brownish black buildup in the bottom of the pan and on the side and corn kernels floating in the water. 4. On 12/06/21 at 10:18 AM, there were no control knobs on the right oven door. The knobs operated the top of the grill and the right oven. DE #1 was asked, How do you regulate the temperature on the grill? She said, We haven't had knobs since I have been here. You just have to turn it until you get it right. The inside of the oven had a thick black buildup of a hard baked substance. The fryer by the right side of the stove had food crumbles all in the tray by the oil. There was a thick buildup of a brown sticky substance on the tray of the fryer. On the back of the fryer was a thick brown sticky substance approximately 1/4 inch thick with food crumbles in the substance all the way to the floor. Beneath the fryer was a sticky brownish black substance approximately 1/4 inch thick with food crumbles in the substance on the floor. On the floor between the fryer and the stove, there was a french fry and an onion ring. 5. On 12/06/21 at 10:21 AM, there was a buildup of a brownish black substance approximately 1/4 to 1/2 inch thick on the grill and the vent-a-hood above the stove had a thick brown sticky substance approximately 1/4 inch thick. DE #1 was asked, Should that be above the stove? She said, No. On the top of the stove around the burners, there was a brown to black substance. DE #1 was asked, Should that be on the stove top? She said, No, we have not cleaned up from breakfast. The floor in the dirty area of the kitchen had a buildup of a black substance approximately 1/4 to 1/2 inch thick in the corners of the floor. 6. On 12/06/21 at 10:27 AM, there were white crystal particles, and a sticky brown residue around the tea machine. DE #1 was asked, Can you tell me what that is? She said, It is where sugar and tea spilled. 7. On 12/06/21 at 12:07 PM, there was a brown food substance in the blender and on the lid of the blender and on the base for the blender there were dried food particles DE #1 retrieved 7 scoops of chicken and dumplings from the steam table to puree. She poured the dumplings into the blender and placed the lid on the blender. She then removed the lid and said, Someone didn't clean that from breakfast. She then ran the lid through the dishwasher cycle. She brought the lid back to the blender with water dripping from the lid and placed the lid on the blender. She turned the blender on with her hands dripping water and touched the base of the blender where there were dried food particles. She then used a spatula to scrape the pureed dumplings into a pan and placed the pan on the steam table. She placed the blender into the dirty side of the dishwasher to be washed. After the blender had been washed, she retrieved the blender and, with water dripping from the blender, she placed it on the base and added 7 scoops of green beans to be pureed. 8. On 12/06/21 at 12:25 PM, DE #1 pulled up her pants with both hands. She then cut the cornbread into 7 squares. She placed the cornbread into the blender with water dripping from the blender and pureed. She then used a spatula and scraped the cornbread out of the blender into a pan with the water dripping from the pan. She then placed the pan of pureed cornbread on the steam table. A small amount of water from the steam table splashed into the pan of the cornbread. 9. On 12/06/21 at 12:30 PM, DE #3 placed the blender on the base for the blender with water dripping. He then placed 7 pieces of cake into the blender. He sat the lid to the blender on the counter with the inside facing down next to the dirty sink. He then wiped his hands on his pants legs. He picked up the lid to the blender with his right thumb touching the inside of the lid and placed the lid on the blender and turned the blender on. He opened the lid to the blender and placed an unmeasured amount of milk into the blender and placed the lid back onto the blender. He used his right hand to push up his left sleeve. He retrieved a spatula and 5 dessert cups. He poured an unmeasured amount of puree cake into each dessert cup. He covered the cups and placed on the serving line. 10. On 12/06/21 at 12:30 PM, DE #1 was asked, Should staff wipe their hands on their clothes and then serve? She said, No. DE #1 was asked, Should you place the lid with the inside face down on a counter next to the dirty sink? She said, No.

Based on observation, record review and interview, the facility failed to ensure toenail care was regularly provided to prevent potential infection or other complications for 3 (Residents #2, #13 and #14) of 20 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #20) sampled residents who were dependent on staff for nail care. The findings are: 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/22 documented the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required extensive physical assistance of one person with personal hygiene, and was totally dependent on one person for bathing. a. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care with a revision date of 10/22/21 documented, .Resident #2] has an ADL [activities of daily living] self-care performance deficit r/t [related to] dementia, head injury and [CONDITION(S)] [[CONDITION(S)]] . Bathing: [Resident #2] is dependent on 1 staff with bathing/showers . Nail Care: Check nail length, trim and clean as necessary . Personal Hygiene: [Resident #2] is dependent on 1 staff with personal hygiene. c. On 02/09/2022 at 3:10 PM, Resident #2 was lying in bed. The toenails on the great toes extended 1/4 inch over the ends of the toes. 2. Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 01/21/22 documented the resident scored 4 (0-7 indicates severely impaired) on a BIMS and required limited physical assistance of one person for personal hygiene and bathing. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care with a revision date of 12/16/21 documented, .Resident #13] has an ADL self-care performance deficit . Bathing: [Resident #13] requires limited assistance with bathing. Personal Hygiene: [Resident #13] requires extensive assistance x 1 staff with personal hygiene . [Resident #13] has Diabetes Mellitus. Diabetic Toe Nail Care to be provided by Licensed Staff . Refer to podiatrist for foot care as needed . c. On 02/07/22 at 2:23 PM, Resident #13 was lying in bed,. The resident's feet were uncovered. The toenails on both feet extended 1/4 inch over the ends of the toes; the great toenail on the right foot was sharp and extended 1/2 inch outward. The middle toenail on the left foot extended over and underneath the pad of the toe. d. On 02/08/22 1:02 PM, Resident #13 was sitting up in bed eating. The resident was asked if his toenails had been cut. He stated, No. e. On 02/09/22 at 3:33 PM, the Administrator was informed of Resident #13's toenails and accompanied the Surveyor to observe them. 3. Resident #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 12/6/21 documented the resident scored 7 (0-7 indicates severely impaired) on a BIMS, required limited physical assistance of one person with personal hygiene, and required physical help for transfer only with the assistance of one person for bathing. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care dated 10/26/21 documented, [Resident #14] has an ADL self-care performance deficit r/t . weakness & [and] cognitive impairment d/t [due to] dementia . Bathing: [Resident #14] requires limited staff assistance with bathing/showering Personal Hygiene: .is independent with personal hygiene. c. On 02/07/22 at 2:28 PM, Resident #14 was lying in bed awake. The toenails on both feet were greater than 1/4 inch long and curved over the tips of the toes. d. On 02/09/22 at 3:38 PM, the Administrator was informed of Resident #14's long toenails and accompanied the surveyor to Resident #14's room. The resident was lying in bed awake; her toenails were greater than 1/4 inch long and curved over the tips of the toes on both feet. 4. A written statement provided by the MDS Coordinator on 2/10/22 at 4:19 PM documented, We do not have a formal policy regarding nail care. However, as staff provide care, they are required to observe nails, and if it is necessary to trim, they do so at that time. 5. On 02/10/22 at 4:27 PM, Certified Nursing Assistant (CNA) #1 was asked, When should you, trim, clean, or cut a resident's toenails? CNA #1 stated, On shower days and as needed. 6. On 02/10/22 at 4:30 PM, CNA #2 was asked, When should you, trim, clean, or cut a resident's toenails? CNA #2 stated, As often as needed, easier when in shower, check every day to see if they need cleaning. 7. On 02/10/22 at 4:35 PM, CNA #3 was asked, When should you, trim, clean, or cut a resident's toenails? CNA #3 stated, On shower days and as needed; CNAs can't cut diabetic nails, the nurses have to do it.

Based on interview and record review, the facility failed to ensure residents and their family and/or their representatives were regularly provided with the opportunity to participate in establishing goals and making care planning decisions to protect resident rights for 2 (Residents #53 and #66) of 22 (Residents #75, #129, #34, #16, #38, #64, #66, #30, #53, #54, #18, #76, #19, #20, #49, #55, #2, #12, #47, #58, #61 and #32) sampled residents whose care plan was reviewed. This failed practices had the potential to affect all 76 residents, as documented on the Resident Census and Conditions of Residents form dated 12/07/21 at 3:00 PM. The findings are: 1. Resident #53 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set MDS with an Assessment Reference Date (ARD) of 11/09/21 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). As of 12/8/21, the most recent documentation of a care plan meeting in Resident #53's electronic clinical record was dated 2/22/21. There was no documentation of MDS Care Planning Notes or notifications to representatives of scheduled care plan meetings since 02/22/21. 2. Resident #66 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 11/18/21 documented the resident scored 1 (0-7 indicates severely cognitively impaired) on a BIMS. As of 12/8/21, the most recent documentation of a care plan meeting in Resident #66's electronic clinical record was dated 2/25/21. There was no documentation of MDS Care Planning Notes or notifications to representatives of scheduled care plan meetings since 2/25/21. 3. On 12/08/21 at 10:17 AM, the long-term care (LTC) MDS Coordinator was asked, How often should residents or their representative be involved or asked to be involved in the care planning process? The MDS Coordinator stated, Quarterly, they are supposed to be done quarterly. The MDS Coordinator was asked, Can you tell me why [Resident #53] and [Resident #66] have not had care plan meetings since February 2021? The MDS Coordinator stated I am not positive. I can get with the Medicare MDS Coordinator and ask. The MDS Coordinator was asked, You would take notes in a care plan meeting, correct? The MDS Coordinated stated, Yes you would. The MDS Coordinator was asked, So, if there is no documentation, or notes, is it safe to assume they did not occur? The MDS Coordinator stated, I'm not sure. 4. On 12/08/21 at 10:27 AM, the LTC MDS Coordinator stated, We have no documentation that care plan meetings have been held since February [2021] for those residents. 5. On 12/08/21 at 12:32 PM, the LTC MDS Coordinator was asked to provide a list of residents who had care plan meetings, with notification to the resident/representative in the last three months. The MDS Coordinator stated, I'm just going to tell you, we have not had any care plan meetings in 3 months for any resident .

Based on observation, record review and interview, the facility failed to ensure information regarding residents' advanced directives and / or code status was accurately documented and readily available to enable staff to quickly ascertain the residents' wishes in the event of a decline in condition for 2 (Residents #2 and #16) of 6 (Residents #49, #16, #55, #32, #2, and #18) sampled residents whose Advance Directive information was reviewed. The findings are: 1. Resident #16 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (,d+[DATE] indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. The Care Plan dated [DATE] documented, .I am a Full Code . b. The Advanced Directive / Medical Treatment Decisions Receipt signed by Resident #16's representative on [DATE] documented, .I have an Advance Directive and have provided a copy to this Facility . c. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Full Code as of [DATE] . d. On [DATE] at 11:09 AM, the Administrator was asked to provide a copy of Resident #16's Advance Directive. e. On [DATE] at 3:28 PM, the Administrator provided a document titled, Resident DNR [Do Not Resuscitate] / CPR [Cardiopulmonary Resuscitation] Instruction, signed by Resident #16's representative on [DATE], which documented, .I want CPR . The Administrator was again asked to provide Resident #16's Advance Directive, as referenced on the Advanced Directive / Medical Treatment Decisions Receipt signed by Resident #16's representative on [DATE]. f. A Social Note dated [DATE] at 13:28 (1:28 PM) by the Social Services Director (SSD) documented, .This SSD spoke to resident's spouse, [Name], concerning his advance directives that she had checked the wrong box and that the resident does not actually have an advanced directive . g. On [DATE] at 11:16 AM, Assistant Director of Nursing #1 was asked why the Advanced Directive documentation should be accurate in the medical record. She stated, You would not be able to follow the resident's wishes. 2. Resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan with a revision date of [DATE] documented, . [Resident #2] have requested that no CPR measures be performed. My code status is DNR . b. On [DATE] at 8:17 PM, Resident #16's electronic health record (EHR) documented a new order for Hospice dated [DATE]. A Do Not Resuscitate (DNR) order dated [DATE] was signed by the physician and scanned into Resident #2's EHR on [DATE]. There was no code status on Resident #2's care profile in the EHR or on the Order Summary Report dated [DATE]. c. On [DATE] at 11:00 AM, the Director of Nursing (DON) was asked about the facility's policy regarding code status orders. She replied, Must have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . d. On [DATE] at 3:30 PM, the DON was asked to look in Resident #2's EHR for the resident's code status. The DON looked at the care profile in the EHR and stated, Well, I would say she is probably a DNR due to Hospice admit orders. The DON then looked at the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, record review, and interview, the facility failed to ensure residents' fingernails were clean and trimmed to promote good personal hygiene and grooming for 2 (Residents #53 and #66) and failed to ensure regularly scheduled bathing was provided to maintain good hygiene for 1 (Resident #54) of 38 (Residents #4, #52, #26, #7, #64, #45, #66, #49, #12, #47, #30, #129, #10, #6, #34, #58, #60, #53, #27, #61, #63, #41, #16, #55, #32, #51, #38, #25, #17, #2, #35, #39, #68, #48, #56, #54, #70 and #18) who were dependent on staff for fingernail care and required assistance with bathing. These failed practices had the potential to affect 67 residents who required assistance for nail care and bathing according to lists provided by the Director of Nursing (DON) on 12/08/21at 2:04 PM. The findings are: 1. Resident #53 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/09/21 documented the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance with personal hygiene. a. The Care Plan with a revision date of 05/13/21 documented, .has an ADL [activities of daily living] self-care performance deficit r/t [related to] [CONDITION(S)] [[CONDITION(S)]] and impaired cognition . requires extensive assistance of 1 staff with bathing/showering . requires extensive assistance with personal hygiene/oral care . b. On 12/06/21 at 11:29 AM, Resident #53 was sitting on the side of his bed. His fingernails on both hands were long, extending approximately 1/4 inch beyond the fingertips, and there was a large amount of a black substance underneath the nails. c. On 12/07/21 at 12:57 PM, Certified Nursing Assistant (CNA) #5 accompanied the surveyor to Resident #53's room and was asked, Can you describe what you see with [Resident #53's] nails? CNA #5 stated, They are too long and filthy. CNA #5 was asked, Who is responsible for trimming the resident's nails? CNA #5 stated, We are. We do it when they shower. CNA #5 was asked, When was his last shower? CNA #5 stated, This morning. CNA #5 was asked, His nails were not trimmed with today's shower? CNA #5 Stated, No. CNA #5 was asked why not and stated, We are busy. 2. Resident #66 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 11/18/21 documented the resident scored 1 (0-7 indicates severely impaired) on a BIMS and required extensive physical assistance of one person with personal hygiene and limited physical assistance of one person with bathing. a. The Care Plan with a revision date of 09/15/21 documented, .has an ADL self-care performance deficit r/t impaired mobility and dementia . is dependent on 1 staff with bathing . requires extensive assistance x 1 staff with personal hygiene . b. On 12/06/21 at 11:26 AM, Resident #66 was in his room lying in bed. His fingernails on both hands were long, extending approximately 1/4 inch beyond the fingertips, and had a black substance underneath them. c. On 12/07/21 at 12:56 PM, Resident #66 was walking in the hallway. His fingernails remained as previously described on 12/6/21. d. On 12/07/21 at 1:48 PM, Licensed Practical Nurse (LPN) #1 accompanied the surveyor to Resident #66's room. Resident #66 was asked to lift his hands. LPN #1 was asked, What do you see? LPN #1 stated, I see dry skin. LPN #1 was asked, And his nails? LPN #1 stated, They are very long. LPN #1 was asked, Do you see anything under the nails? LPN #1 stated, Dirt, there is a lot of dirt. LPN #1 was asked, Who is responsible for nail care? LPN #1 stated, We all are. 3. On 12/07/21 at 3:02 PM, the MDS Coordinator was asked, Can you describe what you see on [Residents 53's] and [Resident 66's] nails? The MDS Coordinator looked and stated, Oh no! Those are long and filthy. At the very least they should be using an orange stick to get them clean. 4. On 12/08/21 at 8:42 AM, the Assistant Director of Nursing (ADON) was asked to define well-groomed. The ADON stated It would be neatly combed hair, clean fingernails. The ADON was asked, Can you tell me what you see here on [Resident #53's] hands? The ADON stated, It looks like the nails are not trimmed or neat, and it looks like they are dirty. Can you tell me what you see here on [Resident #66's] hands? The ADON stated, The same as [Resident #53's], the nails are not trimmed or neat, and they are very dirty. The ADON was asked, Who is responsible for trimming nails? The ADON stated, The Certified Nursing Assistants [CNAs], usually on their shower days, but you should look at them [nails] daily, especially if someone feeds themselves The ADON was asked, Why is it important to keep nails clean for residents who feed themselves? The ADON stated, Hygiene, infection control, dirty nails could harbor all sorts of things. The ADON was asked, Is there a reason the CNAs would not provide nail care? The ADON stated, Sometimes they are not done then [during shower] due to time, but later in the day when they [CNAs] can. The ADON was asked, How long should those nails be before trimmed? The ADON stated, They should never have gotten that long. 5. On 12/08/21 at 10:04 AM, Registered Nurse (RN) #1 was asked, Why is it important to keep the hands and fingernails clean for residents who are independent with eating? RN #1 stated, Infection control primarily, and dignity. 6. On 12/08/21 a 10:05 AM, the Lead CNA was asked, Why is it important to keep the hands and fingernails clean for residents who are independent with eating? The Lead CNA stated, They put their hands in their mouth, potential for E. coli [Escherichia coli (bacteria)] or other infections. 7. Resident #54 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 11/10/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and required limited physical assistance of one person with bathing and personal hygiene. a. The Care Plan with a revision date of 07/09/21 documented, .has an ADL self-care performance deficit r/t limited functional mobility and [CONDITION(S)] . is dependent on 1 staff with bathing . b. On 12/08/21 at 9:25 AM after being asked for documentation of baths provided to this resident, the Assistant Director of Nursing (ADON) provided 4 Resident's Shower/Body Observation forms dated 10/27/21, 11/02/21, 11/12/21, and 12/03/21 and stated, This is all I have. c. On 12/08/21 at 10:04 AM, RN #1 was asked, Are the 'Resident's Shower/Body Observation' forms completed with each shower? RN #1 stated, They are supposed to be. Do I check every one of them? No. The CNA Lead monitors that. d. On 12/08/21 at 10:05 AM, the Lead CNA was asked, Are Resident's Shower/Body Observation forms completed with each shower? The Lead CNA stated, They are supposed to be and they [CNA staff] all know they are supposed to. The Lead CNA was asked, If there was not a Resident's Shower/Body Observation form filled out, would that indicate the resident did not have a shower? The Lead CNA stated, I would hope it doesn't. The Lead CNA was asked, How do you handle refusals? The Lead CNA stated, They are charted in the Kiosk and they still fill out the form [Resident's Shower/Body Observation] to give the floor nurse for follow-up. The Lead CNA was asked, If there was not a form indicating a refusal, the resident had no refusals, is that correct? The Lead CNA stated Yes, they did not refuse showers. e. On 12/08/21 at 10:49 AM, the ADON was asked, Are Resident's Shower/Body Observation forms completed with each shower? The ADON stated, They should be. The ADON was asked, If you do not have a form completed for other dates, does that indicate a shower was not provided? The ADON stated, Yes, if it is not documented, we cannot prove they [CNAs] are doing their jobs. The ADON was asked, Based on the documentation you provided earlier, [Resident #54] has only had four showers between 10/27/21 and 12/03/21, is that correct? The ADON stated, Yes, this is the only documentation I have to show when she has showered. f. On 12/08/2021 at 11:10 AM, Resident #54 stated, I only bathed twice last month and so far, only once this month.

Based on observation, record review and interview, the facility failed to ensure the Care Plan was revised to include the need for contact isolation precautions to prevent the potential spread of infection for 1 (Resident #16); and failed to ensure the care plan was revised to address the care and monitoring necessary to address a urinary tract infection ([CONDITION(S)]) for 1 (Resident #34) of 22 (Residents #75, #129, #34, #16, #38, #64, #66, #30, #53, #54, #18, #76, #19, #20, #49, #55, #2, #12, #47, #58, #61 and #32) sampled residents whose care plans were reviewed. The findings are: 1. The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, October 2019, Chapter 4, documented, .the care plan must be reviewed and revised periodically and the services provided or arranged must be consistent with each resident's written plan of care . the care plan should be revised on an ongoing basis to reflect changes in the resident and the care the resident is receiving . the overall care plan should be oriented towards . individualized interventions . preventing avoidable declines . managing risk factors . 2. Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), had an indwelling catheter and did not have an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan dated as initiated 11/11/21 documented, [Resident #16] has a Urinary Tract Infection . Give antibiotic therapy as ordered . b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation added to the Care Plan regarding the need for contact isolation precautions. c. On 12/6/21 at 10:12 AM, Resident #16 was in his room with the door closed. An Isolation and Contact Precautions sign were on the door. A plastic cart with personal protective equipment (PPE) was outside the door. Certified Nursing Assistant (CNA) #3 was asked, Why is this resident in isolation? She answered, He has VRE in his catheter. 3. Resident #34 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 11/02/21 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on a BIMS and did not have an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan dated as initiated 11/05/21 did not document a Urinary Tract Infection. b. A Urine Culture dated 11/11/21 documented, .[greater than] 100,000 CFU/mL [colony-forming units per milliliter] Pseudomonas aeruginosa . Sensitivity . [MEDICATION(S)] . c. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet via G (gastrostomy)-Tube two times a day related to Urinary Tract Infection, Site not Specified for 7 Days . 4. On 12/08/21 at 11:16 AM, Assistant Director of Nursing (ADON) #1 was asked, What is a care plan? She answered, What you go by to take care of the residents. She was asked, Should Transmission Based Precautions be documented on the care plan? She answered, Yes. She was asked, Should Urinary Tract Infections be documented on the care plan? She stated, Yes.

Based on observation, record review, and interview, the facility failed to ensure the facility maintained quarantine/isolation precautions, including cohorting and that an effective method was in place to alert staff and visitors of the need for isolation/quarantine precautions prior to entering the isolation/quarantine room to prevent the potential cross contamination and the development and transmission of COVID -19 for 4 (Residents #9, #10, #11, & #12) of 4 sampled residents who required quarantine/isolation precautions. This failed practice resulted in immediate jeopardy, which caused or could have caused serious harm to 12 residents who resided on 300 Hall intermixed with quarantine/isolation rooms, as documented on the Midnight Census Report provided by the Assistant Director of Nursing (ADON) on 6/28/21. The Administrator was informed of the Immediate Jeopardy on 6/30/21 at 3:33 pm. The findings are: 1. A Centers for Medicare/Medicaid (CMS) memo dated 04/27/21 documented, .Core Principles of Covid-19 Infection Prevention .Effective cohorting of residents (e.g., [for example] separate areas dedicated to Covid-19 care) . These core principles are consistent with the Centers for Disease Control and Prevention (CDC) guidance for nursing homes, and should be adhered to at all times . 2. Resident #11 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set with an Assessment Reference Date of 06/29/21 documented the resident scored 7 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS) and required extensive assist with 2 staff for bed mobility, dressing and toilet use and extensive assist with 1 staff for transfers, personal hygiene and locomotion on unit. a. A doctor's order dated 6/26/21 documented, .Droplet Isolation Precautions for Covid-19 every shift for 10 days . b. On 06/28/2021 at 9:46 a.m., Resident #11 was sitting in wheelchair in the Medicare dining room (Hall 300) with no mask on. The resident's room (room [ROOM NUMBER]) had no signage on the door or wall to identify Quarantine/Isolation, no PPE inside or outside of the room and there were no isolation bins in the resident's room. c. On 06/28/2021 at 11:12 a.m., Resident's #11 room had no signage on the door or wall to identify Quarantine/Isolation, no PPE inside or outside of the room and there were no isolation bins in the resident's room. d. room [ROOM NUMBER] was located next to room [ROOM NUMBER]. There was a resident in room [ROOM NUMBER], lying in the bed and the door was open. There were no physician orders for this resident to be on isolation. 3. Resident #12 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set with an Assessment Reference Date of 06/29/21 documented the resident scored 12 (8-12 indicates moderate impairment) on a BIMS, required extensive assist with two staff for bed mobility, dressing and toileting and extensive assistance with one staff for transfers, locomotion on unit and personal hygiene. a. The physician's order dated 06/26/21 documented, .Droplet Isolation Precautions for Covid-19 every shift for 10 days . b. On 06/28/2021 at 9:45 a.m., the resident was lying in bed in room [ROOM NUMBER], oxygen was in use and an Intravenous Infusion was in progress. The door was open, the room had no signage on the door or wall related to Quarantine/Isolation, no PPE inside or outside of the room and there were no isolation bins in the resident room. c. On 06/28/2021 at 11:21 a.m., room [ROOM NUMBER] room again with no signage on the door or wall related to Quarantine/Isolation nor PPE inside or outside of the room. There were no isolation bins in the resident's room. d. room [ROOM NUMBER] is next to room [ROOM NUMBER]. The door was open to room [ROOM NUMBER] and the resident was sitting on the side of the bed. There were no physician orders for this resident to be on isolation. e. On 06/29/2021 at 12:13 p.m., the Administrator was asked, Why weren't those residents put on quarantine when they had orders to? He stated, I don't have an excuse as to why they weren't in quarantine. He was asked, Who is responsible for that? He stated, Well, I will say in our morning meetings my nurse managers always ask about our new admits and if they've been vaccinated . 4. Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Evaluation dated 06/24/2021 documented, .Resident oriented to person. Bed Mobility - Limited Assist [Assistance]. Ambulation - Unable to ambulate. Locomotion - Limited Assist. Locomotion - Wheelchair. Incontinent of bowel. Always incontinent of bladder. a. A Physician's Order dated 06/24/2021 documented, .Droplet Isolation Precautions for COVID-19 every shift for 10 days . b. On 06/28/2021 at 9:45 a.m., Resident #9 was in room [ROOM NUMBER]A and was lying in the bed. The door to the resident's room was open. There was no signage on the resident's door or wall related to quarantine/isolation. There was no Personal Protective Equipment (PPE) inside or outside of the room. There were no isolation bins inside the resident's room. c. On 06/28/2021 at 11:15 a.m., there was no signage to identify quarantine/isolation on the door or wall of Resident's #9 room. d. room [ROOM NUMBER] was located in between Rooms 309 and room [ROOM NUMBER]. There was a resident in room [ROOM NUMBER] who had no physician orders for isolation. The door to room [ROOM NUMBER] was open. room [ROOM NUMBER] was empty. 5. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Evaluation dated 06/24/2021 documented, .Resident oriented to Person, Place, Environment/Situation. Bed Mobility - Limited Assist. Ambulation - Limited Assist. Devices used for ambulation - Wheelchair. Toileting - Limited Assist. Locomotion - Limited Assist. Continent of Bowels. Occasionally incontinent of bladder. a. A Physician's Order dated 06/24/2021 documented, .Droplet Isolation Precautions for COVID-19 every shift for 10 days . b. A Care Plan dated 06/28/2021 documented, .COVID-19 I require isolation for transmission-based precautions. Administer my medications as ordered. Monitor for side effects. Encourage me to use clean hygiene techniques to avoid cross-contamination, especially hand washing before meals and after bowel movements . If I must leave my room or the facility, lace a facemask over my nose and mouth . Maintain Droplet Isolation Precautions when caring for resident . Document and report if I have any signs and symptoms of fever, coughing, runny nose, sore throat, nausea, vomiting, headache, chest pain, confusion, muscle aches, shortness of breath, diarrhea, respiratory issues and/or changes in condition. Notify MD/ [Medical Doctor] Practitioner . Follow Facility Protocol for COVID-19 Screening/Precautions . c. On 06/28/2021 at 9:40 a.m., Resident #10 in room [ROOM NUMBER]A was in the bed sleeping with oxygen in use. The door to the resident's room was open. There was no signage on the resident's door or wall to identify quarantine/isolation status. There was no PPE inside or outside of the room. There were no isolation bins inside of the resident's room. d. On 06/28/2021 at 11:20 a.m., there was no signage to identify quarantine/isolation status on the door or wall of Resident's #10 room. e. room [ROOM NUMBER]A was located in between Rooms 319 and room [ROOM NUMBER]. There was a resident in 319 who had no physician orders for isolation. The door to room [ROOM NUMBER] was open. room [ROOM NUMBER] was empty. f. On 06/30/2021 at 10:24 a.m., Certified Nursing Assistant (CNA) #1 was asked what hall she work on and what she knew about quarantine and isolation of residents. She stated, I work on 300 Hall. I know if a resident is in isolation or quarantine by knowing of any symptoms and being informed about it and any signs on the door. I worked on Monday. I remember seeing signs on the doors on Monday on the rooms of [Resident #12]. I was not aware of [Resident #11] being in isolation. I saw signs on the door of [Resident #9]. The signs tell us that residents are in Droplet Precautions and what PPE to wear. [Resident #11] has not been in isolation. I do not work the weekends. g. On 06/30/2021 at 10:34 a.m., the Director of Nursing (DON) was asked about quarantine/isolation status for the resident and how the staff would know who is on isolation precaution. She stated, The staff know of residents in isolation or quarantine by the signs on the door and verbal communication. All of our new admits, come through 300 Hall when arriving to facility. They are placed in rooms on the 300 Hall. The staff on 300 Hall are more knowledgeable of new admits. Residents that should have been in quarantine on 6/28/2021 were [Resident #12 and Resident #9]. I cannot say 100% but I think that there was signage on these doors. The policy for new admissions or readmissions. If a resident is not fully vaccinated, they are quarantined. We test on Day 1, Day 7 and Day10. Residents that are fully vaccinated do not have to be quarantined. If a resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [Resident #12] was admitted on Saturday, [6/26/21] we reviewed the information on Monday, we discovered that we did not have the appropriate equipment in place. If a resident tells us that that they have been fully vaccinated we do not take their word for it, we check to make sure that they were vaccinated. We knew before Monday that Resident #10 and Resident #11 had been vaccinated and should not have been on isolation. Both Resident #9 and Resident #12 should have been quarantined. There is no way to prove that these residents were in isolation. The two ADONs (Assistant Director of Nursing) take care of all the COVID information. The nurse on the weekends would not know to put a sign up on new admissions. h. On 06/30/2021 at 10:52 a.m., CNA #2 was asked about residents on quarantine. She stated, I usually work 100 Hall. I am filling in on 300 Hall today. Residents will have signs on their door if they are in quarantine or isolation. If there is not a sign on the door, I do not think that the resident is in isolation. I started filling in on 300 Hall last week. I worked on Friday. I did work Monday on 300 Hall. I do remember if I recall correctly that were some signs on the doors on 300 Hall. I did not see them when I first came on duty. We do usually ask on the new admissions if they are supposed to be in quarantine. i. On 06/30/2021 at 10:58 a.m., Licensed Practical Nurse (LPN) #1 was asked about her knowledge of quarantine status. She stated, We have signs up and we keep the doors shut on residents that are in isolation or quarantine. There is a plastic drawer outside of the room with PPE. We can also pick it up in PCC (Point Click Care). I work 300 Hall. I do not work the weekends. I did not see any signs on the doors on Monday when I came to work. Signs were placed on the doors throughout the morning. We had a new admission over the weekend that should have been in isolation. There were other residents that should have been in isolation. I got with the DON on Monday when she arrived. The residents usually stay in their room. The staff would not have known that residents were in isolation if there were no signs on the door. We did know that Resident #12 was a new admission and was in isolation. The DON, Administrator and the two ADONs inform us of who should be isolation. j. On 06/30/2021 at 11:08 a.m., CNA #3 was asked how she knew residents were in isolation. She stated, I usually work on 300 Hall. I returned from vacation yesterday. I left last Thursday. If someone tells me, like the nurse, the Unit Manager or DON comes to tell us that a resident is in isolation we will put the signs on the door. If there are signs on the door, we know that a resident is in isolation. If there is not a sign on a resident's door it is my understanding that they are not in isolation. k. On 06/30/2021 at 11:13 a.m., Registered Nurse (RN) #1 was asked about the quarantine status for the residents. She stated, there is usually a sign on the resident's door if they are in isolation or quarantine. I am usually careful back there until the ADON finds out the vaccine status. l. On 06/30/2021 at 11:24 a.m., RN #2, was asked how she knew when residents were on isolation or quarantine. She stated, Their nurse has it on her report sheet which residents are in isolation or quarantine. There are signs on the door. A resident who has been vaccinated may stay in quarantine until we have proof of the vaccine. If a resident has not been vaccinated, they stay in quarantine for 10 days, we test on the first day. Even if a test is negative the resident will stay in quarantine for 10 days. Usually in the past the Admissions/Social worker had been putting up the signs. If a resident is admitted in the evening or over the weekend the nurse will put up the signs. I have no explanation for signs not being placed on the doors on 300 Hall. I have been told that there were no signs on doors on 300 Hall on Monday morning. The other ADON and I will now be responsible for placing the signs on the doors. We look at all of the referrals prior to admission and the admissions personnel will check the vaccine status. That is how she knows if a resident should be in quarantine. m. On 06/30/2021 at 11:35 a.m., the Marketing/Admissions Staff was asked about her role in the admission process for quarantine residents. She stated, Typically, I have been responsible for placing isolation signs on doors of residents in quarantine or isolation. The nurses will do it in the evening or weekends. Before a resident is admitted , I ask the case manager at the hospital or family member if resident has had the vaccine. I will ask for documentation. If a resident has proof of vaccination, they are not placed in quarantine. If a resident has not been vaccinated, they are quarantined for 14 days. We keep these residents on 300 Hall. The staff know if a resident is in isolation by the sign on the door and we tell them. We discuss it in the morning meetings. I was off most of last week and weekend. I am not sure why there was a delay in getting the sign up for [Resident #12], resident refused the vaccine. [Resident #9] was in respite; she came in when I was gone. n. A policy titled Infection Prevention and Control . provided by the Administrator on 06/28/2021 at 3:40 p.m. documented, The nursing facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary .environment and to prevent the development and transmission of communicable disease and infection. This program is comprised of the following resources and infection control manual: Centers for Disease Control and Prevention Guidelines . o. A policy titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes provided by the Administrator on 06/30/2021 at 12:20 p.m., documented .New Admissions and Residents who Leave the Facility .In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission . 6. On 06/30/2021 at 3:33 p.m., the plan of Removal was accepted, and the scope and severity lowered to an E level when the Administration provided the following documentation: 1). On 6/30/2021, 2 Residents who are currently on quarantine were moved to the end of 300 Hall and plastic was placed in hallway to form a separate space for quarantine residents. 2). On 6/30/2021, the 2 residents that were on quarantine had signs removed from outside their current door and placed outside their door in the separate quarantine area to designate that they were on quarantine. 3). Facility Administrator immediately began in-servicing nurses currently working on 6/30/2021 on the placement of residents on quarantine in a separate location from residents who were not on quarantine to prevent the cross contamination and the potential development of COVID 19. Nurses will continue to be in-serviced prior to their shift before working on the floor. 4). Ongoing - Upon admission the DON/Designee will review paperwork and determine whether the resident should be placed in quarantine. If it is determined that resident should be on quarantine, the patient will be placed in the separate area designated for quarantine residents and a sign will be placed outside their door designating that the resident is on quarantine. 5). Plan will be reviewed by facility weekly and modifications and changes will be made as needed.

Complaint # (AR 655) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure falls were evaluated for causative factors and that interventions based on those causative factors were developed, care planned, communicated to staff and consistently implemented and failed to ensure the interventions were evaluated for effectiveness and revised when ineffective to prevent further falls and / or minimize the potential for fall-related injuries for 2 (Residents #1 and #7) of 7 (Residents #1 - 7) case mix residents who had a history of [REDACTED].#1, who sustained a left femoral neck fracture due to a fall, and Resident #7, who sustained a hip fracture due to a fall. The failed practices also had the potential to cause more than minimal harm to 62 residents who had a history of [REDACTED]. The facility was informed of the Immediate Jeopardy condition on 12/22/16 at 8:47 p.m. The findings are: 1. The facility's Fall Protocol, provided by the Administrator on 12/22/16 at 2:10 p.m., documented, Purpose: 1. To assess resident at risk for falls. 2. To follow up and evaluate all falls. 3. To identify the reason for the fall. 4. To prepare a plan of care to reduce the potential for injury related .Assessment Tools 1. Fall risk assessment and post fall assessment. 2. Event report, 2-sided. 3. Fall investigation report and follow up . Procedure - NOTE: All residents will be assessed for fall risk using the Fall Risk Assessment upon admission, readmission, quarterly, significant change in status and at the time of the fall. Those residents that are determined to be high risk will have care plan indicated. Any time a resident is found on the floor, fall risk protocol should be followed including neuro (neurological) checks if indicated. If a resident rolls off the bed or mattress that is close to the floor this is considered a fall. Charge Nurse Duties . 4. Complete the Event report. 5. Complete fall investigation report front page. 6. Implement intervention to prevent further injury. 7. In-service staff on new intervention as needed . MDS (Minimum Data Set) Duties . 1. Complete the Fall Risk Assessment. 2. Update the Care Plan with new interventions . Director of Nursing or Designee Duties . 1. Complete fall investigation follow up . 2. Review fall risk assessment for completion. 3. Review fall investigation follow up and fall risk during standard of care / fall risk meeting. 4. Follow falling star protocol for placement. 5. Review intervention for appropriate intervention change as needed . Falling Star Program . 1. After second fall within 30 days place resident on falling star. 2. Use star or symbol to alert staff risk for fall. 3. Alert staff to placement on falling star program. 4. Review monthly and prn (as needed) . h. Keep call light in reach when able orientate resident to call light system often as needed . Intervention Resource . 5. Supervise ambulation . 17. Assess for bowel and bladder retraining or scheduled toileting . 20. Assess for alarms or devices . Problem Consider risk factors to the process cognition . prior fall, etc. (et cetera) risk for injury . Approaches . 1. List responsible discipline for each approach. 2. List instructions unique to this resident . General Resident Care Plan Documentation Guidelines . 1. List necessary monitoring and observation. 2. List new intervention developed for each fall with date of implementation. 3. List new intervention on CNA (Certified Nursing Assistant) care plan . 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. The Care Area Assessment (CAA) Report dated 5/23/16 documented the following: 1.) Cognitive loss / Dementia . (Resident #7) had periods of confusion and is forgetful but is easily reoriented. She is awake, alert and oriented to person and environment. Her BIMS - 6/moderate cognitive impairment. She is able to voice wants and needs and interacts well with staff and other residents. Will care plan to avoid problems related to impaired cognition . 2.) Function/Rehab Potential (Resident #7) exhibits ADL self care deficit due to weakness. She needs weight bearing assistance for transfers, dressing, toileting and bathing. Limited assistance is provided with personal hygiene (and) bed mobility. She can ambulate short distance in room with help, she does not walk outside of room. She can self propel wheelchair but is sometimes propelled by staff to distant locations. She is able to feed self. Will care plan to ensure daily needs are met encouraging self performance per ability . 3.) Urinary Incontinence/Catheter .(Resident #7) is fairly continent of bowel and bladder but does have occasional incontinent episode and needs assistance from staff to transfer to toilet safely and for peri-care. She is able to voice urge to toilet. Place on prompted toileting program to decrease frequency of incontinent episodes. Will care plan to avoid problems related to incontinence . 4.) Falls . Per Hx (history) reported by the family (Resident #7) has history of falls. Her fall risk = (equals) 18. Risk is increased due to periods of confusion and poor vision. Her risk of fx (fracture) is increased due to dx (diagnosis) of Osteoporosis. She has bed and chair alarms to alert staff of attempts to transfer unassisted. She is able to ambulate with assistance for very short distances. Will care plan to reduce risk of fall related injury. b. The Quarterly MDS with an ARD of 11/8/16 documented, the resident scored 6 (0-7 indicates severely impaired) on a BIMS, required limited assistance of one person for bed mobility, transfers and personal hygiene, required extensive assistance of one person for toileting, used a walker and wheelchair for mobility, was not steady when walking with assistive device or moving from toilet, had highly impaired vision and had 2 or more falls since admission with no injury. c. Fall Risk Assessment & Post Fall Assessment forms in the resident's clinical record documented the following dates / fall risk scores, with a score of 12 or greater indicating a high risk for falls: 1.) 5/12/16 - total score 7; 2.) 10/4/16 - total score - 15; 3.) 11/30/16 - total score 20. d. The Comprehensive Resident Plan of Care with an initial date of 5/24/16 and updated on 12/20/16 documented, Falls, Problem Date 12/20/16 (Resident's #7) is at risk for falls due to confusion, poor vision, poor safety awareness and fall hx (history). Risk of falls related injury is increased due to dx (diagnosis) of Osteoporosis . Approach .Use fall risk screen to identify risk factors, lock brakes on bed, chair, etc. (et cetera) before transferring. Remind resident and reinforce safety awareness. Provide environmental adaptations. Bed in low position. Call light within reach. Adequate glare free lighting. Area free of clutter. Report labs to the Physician and responsible party. Administer medications for Osteoporosis per MD (Medical Doctor) orders .(hand written) 6/15/16 intervention - Chair alarm, Therapy Screen. 8/2/16- unwitnessed fall reported by roommate, 8/2/16 intervention - Bed Alarm. Check placement and position every shift, appropriate foot wear. 9/27/16 - fall in room, Part B to screen, 9/27/16 - fall in room, 9/29/16 fall in B/R (bathroom), Part B to screen, low bed mat, 10/4/16 - Fall in B/R. 10/23/16 - Fall in room, intervention- encourage to use call light. 11/30/16 - Fall walking to D/R (dining room). 11/30/16 intervention - Sent to Hospital for eval (evaluation). Will re-eval (re-evalluate) per return . e. The Nurses Aide Information Sheet (undated) documented, Safety/Fall Measures, chair alarm, bed alarm, bed in lowest position . ADL Care and Assistance: Turning and Repositioning: Bed-self, Chair assist(ance) of 1, Toileting assist of 1, Location of meals: room . Additional comments/information: May have O2 (Oxygen) PRN (as needed) notify Nurse of short of breath. Remind (and) assist x 1 (with) ADL's. Legally Blind. f. The May, June, July, August, September, October, November and December 2016 Medication, Treatment and Task Administration Record Report documented, Chair Alarm, Chair Alarm while up in wheelchair to alert staff of attempts to rise unassisted, Check placement and function every shift . Bed Alarm to alert staff of attempts to rise unassisted. Check placement and function every shift. Start date 5/12/16. As of 12/23/16 at 12:00 p.m., the Medication Treatment and Task Administration Record Reports for the past 7 months were initialed by nurses each shift to indicate that the chair alarm was checked for placement and function through the day shift on 12/23/16. g. An Event Report dated 5/28/16 at 10:00 a.m. documented, .Type of Event: Fall .Location: Lobby .Describe what occurred: (Resident) observed on floor (no) red marks. Able to move all extremities. Denies pain, alert, Notified APN (Advanced Practice Nurse), Notified daughter . 1.) The SBAR Communication Form and Progress Note dated 5/28/16 (not timed) documented, .Situation: Fall . Nursing Notes: Observed transferring from chair to another chair, slid off chair seat, caught self (with) arm (no) signs of injury, at this point, denies pain . 2.) The Event Follow - Up Progress Notes dated 5/29/16 (not timed) documented, Interventions/Assessment: Awake (and) alert. Moves all extremities equal (and) well. Denies pain (at) present. (Up) in w/c, Chair alarm on (and) functioning. Plans to go out (with family) . The resident's Care Plan was not updated to include a chair alarm until 6/15/16 (refer to paragraph 'f' above). h. The Event Report dated 6/13/16 at 6:00 a.m. documented, Type of Event: Fall . Describe what occurred: I was entering room to administer meds (medications) to R (Resident). She was exiting the bathroom and fell to her knees. Assessed R, (no) signs of swelling and (no) bruising noted. (No) c/o (complaints of) pain or discomfort. Assisted R into wheelchair . Immediate or Initial Interventions: Chair Alarm and consult (with) PT (Physical Therapy) and walker per family request . Recommendations and or new interventions - Review interventions initiated at time of event to ensure appropriateness: Chair Alarm, to alert staff of attempts to rise from w/c unassisted. Function checks . The Event Investigation Report dated 6/13/16 at 6:00 a.m. documented: .Type of transfer assistance required - specify: 1 person assist. 1.) The SBAR Communication Form and Progress Note dated 6/13/16 (not timed) documented, Situation - Fall. 2.) The Event Follow-up Progress Notes dated 6/13/16 documented, Investigation / Assessment: No discoloration to either knee. (Up) sitting in w/c in D/R (dining room), denies pain nor discomfort. Chair alarm functioning properly. No (change) in ROM (range of motion) . i. The Event Report dated 8/2/16 at 3:10 p.m. documented, Type of Event: Fall . Describe what occurred: Room-mate states that 'My room-mate fell earlier'. Upon questioning res. (resident), Res states 'Yeah I fell on my knees (and) got up by myself. I'm not hurt'. Upon assessment no injuries were noted. Stated got off bed was walking to my recliner (and) fell on knees at foot of bed. (No) injuries noted. Moving all ext (extremities) (without) problems. Res noted to be in socks . Immediate or Initial Interventions: make sure alarms are in place (and) working properly, Shoes on when (up) amb (ambulating) . Follow up: Check placement (and) function of alarms (every) shift . Recommendations and / or new interventions - Review Intervention initiated at time of event to ensure appropriateness. Alarm to be checked for placement (and) function every shift frequent checks. The only new intervention documented was to ensure resident was wearing shoes when ambulating; however, there was no indication that the care planned alarms alerted staff when the resident got up to ambulate on this occasion. 1.) The SBAR Communication Form and Progress Note dated 8/2/16 at 3:10 p.m. documented, Situation: Fall, Nurses Notes: Roommate tells CNA (Certified Nursing Assistant) that this res (resident) fall. Upon questioning res states Got off bed walking to recliner and I just fell down on knees (at) foot of bed (and) got up by myself.' Denies pain. (No) injury noted. Was in sock feet. Alarm not connected. Not sure if walker was used . There was no documentation of any investigation to determine why the alarm was not connected, i.e. - whether staff forgot to place the alarm or whether the resident was able to remove the alarm herself. 2.) The Event Follow - Up Progress Notes dated 8/3/16 documented, Interventions / Assessment: In room sitting in chair (with) legs extended (and) moving legs back (and) forth, denies pain or discomfort, no (change) in ROM. No stiffness, No indication of bruising. Bed alarm in working order . There was no documentation as to whether a chair alarm was present at this time. j. The Event Report dated 8/20/16 at 5:00 p.m. documented, .Describe what occurred: Resident was seen on (left) knee (and) hand in 400 hallway. Resident was able to get up before help could get to her. Resident stated that she stumbled, caught herself (and) isn't hurting. APRN (Advanced Practice Registered Nurse) notified. Daughter notified. No visible marks on resident . She stated she just got tired (and) started to go down, caught herself (and) got back up . Immediate or Initial Interventions: Assisting resident when walking (and) ensuring proper use of walker . Recommendation and/or interventions - Review intervention initiated at time of event to ensure appropriateness: Reminder to resident to take her time and be more careful (with) ambulation. There was no indication as to whether a chair or bed alarm was sounding at this time and no documentation of any fall prevention interventions, other than reminding the cognitively impaired resident to take her time and be more careful and restating that the resident was to be assisted with ambulation and use a walker. 1.) The SBAR Communication Form and Progress Note dated for 8/20/16, not timed, documented, Situation Fall . Nurses Notes: Resident was seen on (left) knee (and) hand in hallway, no visible s/s (signs and symptoms) of distress or discomfort. Resident stated she was not in pain. 2.) The Event Follow-up Progress Notes dated 8/22/16 documented, Sitting in soft chair in room (with) walker in front of her, no c/o pain or discomfort, no (change) in ROM. No sign of discolored skin. Will cont (continue) to monitor for (changes). There was no documentation as to whether a chair alarm was in place at this time. k. The Rehab / Nursing Training Form dated 9/20/16 documented, From PT (Physical Therapy) discharged Therapy Services on 8/15/16. Plan should be initiated on 9/21/16 frequency 3x wk (3 times per week). Duration 12 weeks. Recommendations. 1. Pt (patient) to walk at least 124' (feet) (with) RW (rolling walker) and close supervision. 2. Standing leg exercises including marching heels raises hip abduction 3 x (times) 10 reps (repetitions). Precautions: Fall risk when fatigued. l. An Event Report dated 9/27/16 at 12:15 p.m. documented, .Describe what occurred: Heard fall, (no) witness, R (Resident) lying on stomach. Neuro (neurological) checks started. Able to move all extremities . Follow Up: Currently being (treated) for pneumonia, res weak will monitor closely (and) frequently check for changes . There was no documentation the resident was asked how the fall occurred, what she was doing at the time of the fall, or whether a chair or bed alarm were sounding at the time of the fall. 1.) The SBAR Communication Form and Progress Note dated 9/27/16 documented, Situation-Fall . Nursing Notes: Heard fall CNAs went running into room observed lying on floor. Stated she fell , L (left) hand. discoloration noted, able to move all extremities (without) pain. 2.) The Event Follow-Up Progress Notes documented, Intervention / Assessment 9/28/16 (Up) in bed, supine, discoloration to left hand (with) full ROM. No noted other areas of injury. No c/o pain nor discomfort . 3.) The Safety Committee Event Investigation Follow-Up Report dated 9/28/16 documented, .Describe corrective actions taken to prevent recurrence of this even: Alarm functioning properly . Recommendation and/new interventions - Review interventions at time of event to ensure appropriateness. Frequent checks, lay Resident down (after) meals (and) when she's tired, cont. (continue) Alarm, don't leave in room for extended periods of time in wheelchair. To rest more in recliner. These interventions were not added to the resident's Care Plan (refer to paragraph 'f' above). m. The Event Report dated 9/27/16 at 12:30 p.m. documented, Type of Event: fall . Description what occurred, called to room by CNA (name) responding to bed alarm. Found resident in floor beside bed. Stated more on L (left) hip, legs bent to R (right) side. No noted injuries, no c/o pain. Assisted to standing position (and) returned to bed . Describe corrective actions taken to prevent recurrence of this event: Bed Alarm functioning properly . Recommendations and/or intervention - Review intervention initiated at time of event to ensure appropriateness: Part B therapy services. Resident reminders to ask for assist when transferring self . 1.) The Event Investigation Report dated 9/27/16 documented, .Cognitive Status, Describe cognitive status before event: Slightly confused. Describe cognitive status after event, Increased confusion. 2.) The SBAR Communication Form and Progress Note dated 9/27/16 documented, Situation Fall . Nurses Notes (for additional information on the Change in Condition): Heard fall CNA's went running into room observed lying in floor. Stated she fell . (L) hand discoloration noted. Able to move all extremities. Neurological Assessment were attached. 3.). The Therapy Screening Form dated 9/28/16 documented, Fall Risk . Referred by NRSG (Nursing), Diagnoses: [REDACTED]. A Communication Form from Therapy to Nursing documented, Referral or Concern. (1) Pt (Patient) should be supervised with mobility due to low vision and poor safety awareness. (2) Recommend moving pats room closer to nurses station as pt quickly fatigues and has difficulty negotiating obstacles . n. The Event Report dated 9/29/16 at 12:00 a.m. documented, Type of Event: Fall - observed on floor . Describe what occurred: Called to rm (room) by CNA, Res (Resident) found in floor (with) Hematoma noted to L (left) eyebrow, Neuro (checks) started (and) WNL (within normal limits). Ice pack applied, intermit (intermittently). Res cont (continues) to remove ice pack . 1.) A Safety Committee Event Investigation Follow-Up Report dated 9/29/16 documented, .Summary of Event / Investigation Need for additional information - Conduct Re-enactment. Found in BR (Bathroom) (with) head under sink, hematoma to (upper) eyebrow area 3 cm (centimeters). Neuro checks begun . Describe corrective actions taken to prevent recurrence of this event: Frequent checking, assure using walker, will have therapy services to screen . Recommendations and / or new interventions - Review interventions initiated at time of event to ensure appropriateness: Low bed (with mat) . The form did not document an explanation as to how a low bed with mat would be effective to prevent further injuries related to falls in the bathroom. 2.) An Event Investigation Report dated 9/29/16 documented, .Cognitive Status: Confused (increased x 2 days), Behaviors: Turned off alarm when (up) to BR (bathroom) . There was no documentation that an evaluation was done regarding whether a different type of alarm was needed, since the resident was able to turn the alarm off independently. 3.) The SBAR Communication Form and Progress Note dated for 9/29/16 documented, Situation: .Fall . There was no documentation in the Nursing Notes section of the form. 4.) The Event Follow-up Progress Notes dated 9/29/16 documented, Therapy has been given a screen request. Hematoma to left eyebrow area, new orders for CBC (complete blood count), BMP (basic metabolic profile), H-pylori (helicobacter pylori), stool specimen, KUB (Kidney, Ureter and Bladder x-ray) for c/o (complaint of) abdominal pain. Placed on Prilosec 40 mg (milligrams) daily. 5.) A Communication Form dated 9/29/16 documented, Therapy to Nursing, Resident concern, Referral or Concern. 1. Pt (patient) should be supervised with mobility due to low vision and poor safety awareness. 2. Recommend moving pt's (patient's) room closer to Nursing Station as pt quickly fatigues and has difficulty negotiating obstacles. o. The Event Report dated 10/4/16 at 5:30 p.m. documented, Type of Event: Fall . Describe what occurred: Called to room per CNA. Upon assessment Res noted in front of bathroom floor sitting on L (left) hip (with) legs bent. Attempting to get up herself. (No) physical injury noted. Moving ext (without) problems. Denies pain . Bed Alarm in place but not proper placement; this alarm did not sound. Immediate or initial Interventions. In-service staff or monitor Res (and) safety equipment. Follow Up: Frequent toileting (every) 2 hours initiating program will encourage to come to DR for meals . 1.) The SBAR Communication Form and Progress Note dated 10/4/16 at 5:30 p.m. documented, Situation: Fall .Nurses Notes: Called to room per CNA. Res seated in front of bathroom floor sitting on L (left) hip (with) legs bent. Attempting to get up per self. Denies pain moving ext (extremities) (without) problem. Assist (up) x 2. Cognitive Status before event, Alert with confusion. Cognitive status after event, Alert with confusion. 2.) A Safety Committee Event Investigation Follow-Up Report dated 10/5/16 documented, .Describe corrective actions taken to prevent reoccurrence of this event: Frequent checks and toileting program (every) 2 hours . Recommendation and /or new interventions - Review intervention initiated at time of event to ensure appropriateness: Plans being made to move res closer to nurses station . This was a period of 6 days after PT documented a recommendation to move the resident to a room closer to the nurses' station. p. The Event Report dated 10/23/16 at 11:18 a.m. documented, Type of Event: Fall . Describe what occurred: R was found in the floor of her room on her coccyx. She stated that she was trying to get some popcorn off the floor (and) slipped. She stated she did not hit her head (and) that she had (no) pain . Immediate or initial Interventions: Instructed on importance of using call light. There was no documentation that any interventions were implemented, other than instructing the cognitively impaired resident to use her call light. The SBAR Communication Form and Progress Note dated 10/23/16 documented, Situation Fall . Nursing Notes: R was found in the floor of her room on her coccyx. She stated that she was trying to get some popcorn off the floor (and) slipped. She stated she did not hit her head (and) that she had (no) pain . Immediate or Initial Interventions: Instructed on importance of using call light . There was no further interventions documented on this form. q. A Physical Therapy Treatment Encounter Note, with certification dates of 10/22/16-11/20/16, documented, 11/3/16 Pt (Patient) amb (ambulated) with RW (rolling walker) 150' (feet), SBA (stand by assist) for initial 50' (feet), then required min/mod (minimal to moderate) A (assistance) secondary to Pt leaning to the R (right), pushing RW too far out in front of her, shuffling gait, while veering sideways. Pt speaking to PT (Physical Therapy), trial w/ (with) weighted 10# (10-pound) RW assessed w/160' (feet) w/ CGA/SBA (Contact/Guard Assistance / Stand-by Assistance) for initial 75' (feet), then requiring min A (assist) w/mod (with moderate) A maneuvering RW . Resident unable to maintain control of AD (assistive device). Comments: Subjective / objective LPN and CNA notified of pt's unsteadiness this date and the need for increased assistance w/ mobility. r. An Event Report dated 11/30/16 at 7:00 a.m. documented, Type of event: Fall . Describe what occurred: Res amb per walker per self on way to DR (dining room). Observed sitting on buttocks. Leaning more to R (right) side, R leg bent at knee and under L leg. Res straights R leg out (without) problem or c/o (complaint of) pain in R leg, hip (and) knee. States someone ran into me. No one around Res. Res legally blind. Cognitive status before event, Alert and confused. Cognitive Status after event, Alert and confused. Res was up against wall beside supply room . Immediate or Initial Intervention: X-ray, R knee, R hip. Sent to (Hospital name) ER (emergency room ) Behaviors . There was no documentation as to whether a chair or bed alarm were sounding in the resident's room at this time. 1.) The SBAR Communication Form and Progress Note dated 11/30/16 at 7:00 a.m. documented, Situation, Fall . Nursing Notes: Res observed sitting on buttocks more on R (right) buttocks (with) R (right) leg bent (at) knee under L leg. Moved both ext. (without) c/o (complaint of). Assist to stand x 2. Would not bear wt (weight) to R assist to wc (wheelchair). States 'someone ran into me.' No one in area. Res was on way to DR (dining room) was against wall next to supply room . 2.) A Safety Committee Event Investigation Follow-Up Report dated 12/1/16 documented, .Describe corrective actions taken to prevent reoccurrence of this event. X-rays obtained to hip (right) . Recommendation and / or new interventions - Review intervention initiated at time of event to ensure appropriateness: Plans being made to move res closer to nurses station. Sent to ER (after) x-ray result (and) is currently in hospital 12/1/16 . This was a period of over 2 months after PT documented a recommendation to move the resident to a room closer to the nurses' station. 3.) The X-ray Onsite Imaging Report dated 11/30/16 at 9:48 a.m. documented, Hip Unilateral w/ Pelvis 2-3 v (views) AP/Lat (anterior / posterior / lateral) DUNN (x-ray at 45 degree angle with hip flexed) RI (right). Reason pain. Impression; Acute, non-displaced right intertrochanteric fracture. s. A Hospital Document Review Report dated 11/30/16 documented, Admit to Inpatient 30 Nov (November)-2016. Hospital Admission Diagnosis, Closed Intertrochanteric Fracture of Right Hip . 11/30/16 11:40 a.m. History Pain with injury. Technique AP (Anteroposterior) pelvis with AP and lateral right hip. Findings; There is an intertrochanteric fracture of the right hip with slight varus angulations. No dislocation is seen. Injury Procedure details . S/P (status [REDACTED]. t. A Hospital Document Review Report dated 12/1/16 documented, .Referral Information: PT Eval and Treatment . Rehab Potential: Fair . Precautions / Limitations: Safety Patient has decreased compliance with precautions / Patient requires cues for hand placement . Patient requires cues for sequencing . Patient requires cues for handling of adaptive equipment . Patient requires second person assist for safety. Barriers to progress: confusion . lethargic . pain, poor carryover of instruction of technique, poor endurance . Fall Assessment Detail: Patient s/p (status [REDACTED]. She will require PT (Physical Therapy) to address the skilled needs listed above in order to return to her PLOF (Prior level of functioning). u. A Hospital Document Review Report documented the resident was discharged back to the facility on [DATE]. v. Nurses Note dated 12/3/16 at 6:00 p.m. documented, R (Resident) laying (sic) in bed . able to bear weight (with) 2 (times) assist to beside commode . w. The Significant Change MDS with an ARD of 12/10/16 documented the resident scored 11 (8-12 indicates moderately impaired cognitive skills) on a BIMS, required the extensive assistance of 2 people for bed mobility, transfers and toileting and 1 person for personal hygiene, required the use of a wheelchair for mobility, had a history of [REDACTED]. This represented declines in ADLs had occurred since the 11/18/16 MDS, when the resident had been assessed as requiring limited assistance of one person for bed mobility, transfers and personal hygiene and extensive assistance of one person for toileting x. An Event Report dated 12/12/16 at 1:20 p.m. documented, Type of Event: Fall . Describe what occurred: This Nurse heard alarm sounding. Upon entering room resident observed sitting on buttocks, more on the R hip in floor in front of recliner. Moving all ext. (without) problem. c/o old pain to R hip. Assisted (up) x 2 to bed. (No) injuries noted. Low bed, CL (call light) in reach. Res states 'Well of course I tried to stand by myself . Immediate or Initial Interventions: X-ray as ordered. Monitor Resident more often to assure needs are being met. 1.) The SBAR Communication Form and Progress Note dated 12/12/16 at 1:20 p.m. documented, Situation Fall . Nursing Notes: This Nurse heard alarm sounding upon entering room, resident noted sitting on buttocks on floor front of recliner, more so on R hip. 2.) The X-ray reports dated 12/12/16 from onsite imaging documented, Hip unilateral w/ pelvis 2-3 V (view) AP / Lat (Lateral) / Dunn Right. Reason: Right Hip pain Post Fall. Impression: Interval post changes of the right femoral intertrochanteric fracture.

Complaint # (AR 655) was substantiated, all or in part, with these findings: Based on record review, and interview, the facility's nursing administration failed to identify and intervene to correct an ongoing, systemic problem with regard to fall and injury prevention, as evidenced by failure to ensure falls were evaluated for causative factors and that interventions based on those causative factors were developed, care planned, communicated to staff and consistently implemented and failed to ensure the interventions were evaluated for effectiveness and revised when ineffective to prevent further falls and / or minimize the potential for fall-related injuries for 2 (Residents #1 and #7) of 7 (Residents #1 - 7) case mix residents who had a history of [REDACTED].#1, who sustained a left femoral neck fracture due to a fall, and Resident #7, who sustained a [MEDICAL CONDITION] due to a fall. The failed practices also had the potential to cause more than minimal harm to 62 residents who had a history of [REDACTED]. The facility was informed of the Immediate Jeopardy condition on 12/22/16 at 8:47 p.m. The findings are: 1. The facility's Director of Nursing Services Job Description, received from the Administrator on 12/22/16 at 2:45 p.m., documented, The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department . to ensure that the highest degree of quality care is maintained at all times. Delegation of Authority as the Director of Nursing Services, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. In the absence of Medical Director, you are charged with carrying out the resident care policies established by this facility .Administrative Functions Plan, develop, organize, implement, evaluate, and direct the Nursing Services Department, as well as its programs and activities . Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care . Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided and that they reflect the resident's response to the care . Safety . Ensure that all nursing service personnel follow established departmental policies and procedures . Care Plan and Assessment Functions Develop preliminary and comprehensive assessments of the nursing needs of each resident. Develop a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care.Ensure that all personnel involved in providing care to the resident is aware of the care plan and that care plans are used in administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed. Review and revise care plans and assessments as necessary . Develop and maintain a good rapport with all services involved with the care plan to ensure that a team effort is achieved in developing a comprehensive plan of care . 2. The facility Assistant Director of Nursing / Relief RN (Registered Nurse) Job Description, received from the Administrator on 12/22/16 at 2:45 p.m., documented, .Responsibilities The staff nurse is responsible to the Director of Nursing service for planning, supervising, and evaluating: 1. All nursing functions during his/her tour of duty. 2. Administration of nursing home routines and policies during his/her tour of duty. 3. See that all personnel on the unit during his/her tour of duty functions to the maximum capacity . Duties Functions related to patient care-provide comprehensive nursing care to all patients by: 1. Cooperating with the supervisor in setting up a nursing care plan for each patient . 5. Directing and supervising the activities of the nursing personnel assigned to the unit during his/her tour of duty. 6. Checking all patients' charts for accurate reporting and recording of symptoms, reactions, and progress. 7. Visiting patients frequently to valuate their condition and need for nursing care . The Administrator stated on 12/22/16 at 2:45 p.m., This job description is also used for the Clinical Manager. 3. The facility Charge Nurse Job Description, received from the Registered Nurse (RN) Consultant on 12/23/16 at 11:00 a.m., documented, The primary purpose of your job position is to supervise the day-to-day nursing activities of the facility during your tour of duty . to assure that the highest degree of quality care is maintained at all times. Delegation of Authority As the Charge Nurse, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Major Duties and Responsibilities Administrative Functions Direct the day-to-day functions ofthe nursing activities . Assist in developing methods for coordinating nursing services with other resident services to ensure the continuity of the resident's total regimen of care. Ensure that all nursing service personnel are following their respective job descriptions . Charting and Documentation Fill out and complete accident/incident reports. Submit to Director as required. Chart all accidents/incidents involving the resident. Follow established procedures . Make periodic checks to assure that care is beingproperly administered by nursing assistants and to evaluate the resident's physical and emotional status.Care Plan and Assessment Functions Review care plans daily to ensure that appropriate care is rendered. Update care plans as residents' condition change. Ensure that your nurse's notes reflect that the care is being followed. Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing need. Ensure that your assigned nursing assistants are aware of the resident care plans and that they are used in administering daily care to the resident . 4. The facility MDS (Minimum Data Set) Coordinator Job Description, received from the Administrator on 12/23/16 at 11:18 a.m., documented, The primary purpose of your job position is to promote the physical and emotional well being of nursing home facility residents through the use of the Resident Assessment Instrument (RAI) to gather information from residents and their families during initial and periodic interviews. Utilizing the Minimum Data Set (MDS) as the key tool in the process of assessing the functional capabilities of residents, the MDS Coordinator formulates, implements and monitors individualized care plans for residents to ensure their effectiveness .Major Duties and Responsibilities .Assist in developing methods for coordinating MDS services with other resident services to ensure the continuity of the resident's total regimen of care . Participate in all Care Plan meetings. Participate in all Standards of Care meetings . Monitor accuracy of CNA Care Plans and effectiveness of communication of change on all LTC (long term care) residents . 5. The facility Fall Protocol received on 12/22/16 at 2:10 p.m. from the Administrator documented, Purpose: 1. To assess resident at risk for falls 2. To follow up and evaluate all falls 3. To identify the reason for the fall 4. To prepare a plan of care to reduce the potential for injury related to falls General Guidelines for Assessment May Include But Not Limited To: 1. Change in physical and/or cognitive function 2. Pain 3. Medication 4. Environmental 5. Communication Deficits 6. Risk factors r/t (related to) disease process, cognitive status, behaviors, etc. Assessment Tools 1. Fall risk assessment and post fall assessment 2. Event report 2 sided 3. Fall investigation report and follow up Procedure NOTE: All resident will be assessed for fall risk using the Fall Risk Assessment upon admission, readmission, quarterly, significant change in status and at the time of the fall. Those residents that are to be determined high risk will have care plan indicated. Any Time A Resident Is Found On The Floor, Fall risk protocol should be followed including neuro checks if indicated. If a resident rolls off the bed or mattress that is close to the floor this is considered a fall. Charge Nurse Duties .4. Complete the Event report 5. Complete fall investigation report front page 6. Implement intervention to prevent further injury 7. In-service staff on new intervention as needed MDS Duties 1. Complete the Fall Risk Assessment 2. Update the Care Plan with new interventions Director of Nursing or Designee Duties 1. Complete fall investigation follow up .2. Review fall risk assessment for completion 3. Review fall investigation follow up and fall risk during standard of care/fall risk meeting 4. Follow falling star protocol for placement 5. Review intervention for appropriate intervention change as needed Falling Star Program 1. After second fall within 30 days fall place resident on falling star 2. Use star or symbol to alert staff risk for fall 3. Alert staff to placement on falling star program 4. Review monthly and prn .h. Keep call light in reach when able orientate resident to call light system often as needed .Intervention Resource .5. Supervise ambulation .17. Assess for bowel and bladder retraining or scheduled toileting .20. Assess for alarms or devices .Problem Consider risk factors to the process cognition .prior fall, etc. risk for injury .Approaches 1. List responsible discipline for each approach 2. List instructions unique to this resident General Resident Care Plan Documentation Guidelines 1. List necessary monitoring and observation 2. List new intervention developed for each fall with date of implementation 3. List new intervention on C.N.A. (Certified Nursing Assistant) care plan . 6. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. The Care Area Assessment (CAA) Report dated 5/23/16 documented the following: 1.) Cognitive loss / Dementia . (Resident #7) had periods of confusion and is forgetful but is easily reoriented. She is awake, alert and oriented to person and environment. Her BIMS - 6/moderate cognitive impairment. She is able to voice wants and needs and interacts well with staff and other residents. Will care plan to avoid problems related to impaired cognition . 2.) Function/Rehab Potential (Resident #7) exhibits ADL self care deficit due to weakness. She needs weight bearing assistance for transfers, dressing, toileting and bathing. Limited assistance is provided with personal hygiene (and) bed mobility. She can ambulate short distance in room with help, she does not walk outside of room. She can self propel wheelchair but is sometimes propelled by staff to distant locations. She is able to feed self. Will care plan to ensure daily needs are met encouraging self performance per ability . 3.) Urinary Incontinence/Catheter .(Resident #7) is fairly continent of bowel and bladder but does have occasional incontinent episode and needs assistance from staff to transfer to toilet safely and for peri-care. She is able to voice urge to toilet. Place on prompted toileting program to decrease frequency of incontinent episodes. Will care plan to avoid problems related to incontinence . 4.) Falls . Per Hx (history) reported by the family (Resident #7) has history of falls. Her fall risk = (equals) 18. Risk is increased due to periods of confusion and poor vision. Her risk of fx (fracture) is increased due to dx (diagnosis) of [MEDICAL CONDITION]. She has bed and chair alarms to alert staff of attempts to transfer unassisted. She is able to ambulate with assistance for very short distances. Will care plan to reduce risk of fall related injury. b. The Quarterly MDS with an ARD of 11/8/16 documented, the resident scored 6 (0-7 indicates severely impaired) on a BIMS, required limited assistance of one person for bed mobility, transfers and personal hygiene, required extensive assistance of one person for toileting, used a walker and wheelchair for mobility, was not steady when walking with assistive device or moving from toilet, had highly impaired vision and had 2 or more falls since admission with no injury. c. Fall Risk Assessment & Post Fall Assessment forms in the resident's clinical record documented the following dates / fall risk scores, with a score of 12 or greater indicating a high risk for falls: 1.) 5/12/16 - total score 7; 2.) 10/4/16 - total score - 15; 3.) 11/30/16 - total score 20. d. The Comprehensive Resident Plan of Care with an initial date of 5/24/16 and updated on 12/20/16 documented, Falls, Problem Date 12/20/16 (Resident's #7) is at risk for falls due to confusion, poor vision, poor safety awareness and fall hx (history). Risk of falls related injury is increased due to dx (diagnosis) of [MEDICAL CONDITION] . Approach .Use fall risk screen to identify risk factors, lock brakes on bed, chair, etc. (et cetera) before transferring. Remind resident and reinforce safety awareness. Provide environmental adaptations. Bed in low position. Call light within reach. Adequate glare free lighting. Area free of clutter. Report labs to the Physician and responsible party. Administer medications for [MEDICAL CONDITION] per MD (Medical Doctor) orders .(hand written) 6/15/16 intervention - Chair alarm, Therapy Screen. 8/2/16- unwitnessed fall reported by roommate, 8/2/16 intervention - Bed Alarm. Check placement and position every shift, appropriate foot wear. 9/27/16 - fall in room, Part B to screen, 9/27/16 - fall in room, 9/29/16 fall in B/R (bathroom), Part B to screen, low bed mat, 10/4/16 - Fall in B/R. 10/23/16 - Fall in room, intervention- encourage to use call light. 11/30/16 - Fall walking to D/R (dining room). 11/30/16 intervention - Sent to Hospital for eval (evaluation). Will re-eval (re-evalluate) per return . e. The Nurses Aide Information Sheet (undated) documented, Safety/Fall Measures, chair alarm, bed alarm, bed in lowest position . ADL Care and Assistance: Turning and Repositioning: Bed-self, Chair assist(ance) of 1, Toileting assist of 1, Location of meals: room . Additional comments/information: May have O2 (Oxygen) PRN (as needed) notify Nurse of short of breath. Remind (and) assist x 1 (with) ADL's. Legally Blind. f. The May, June, July, August, September, October, November and December 2016 Medication, Treatment and Task Administration Record Report documented, Chair Alarm, Chair Alarm while up in wheelchair to alert staff of attempts to rise unassisted, Check placement and function every shift . Bed Alarm to alert staff of attempts to rise unassisted. Check placement and function every shift. Start date 5/12/16. As of 12/23/16 at 12:00 p.m., the Medication Treatment and Task Administration Record Reports for the past 7 months were initialed by nurses each shift to indicate that the chair alarm was checked for placement and function through the day shift on 12/23/16. g. An Event Report dated 5/28/16 at 10:00 a.m. documented, .Type of Event: Fall .Location: Lobby .Describe what occurred: (Resident) observed on floor (no) red marks. Able to move all extremities. Denies pain, alert, Notified APN (Advanced Practice Nurse), Notified daughter . 1.) The SBAR Communication Form and Progress Note dated 5/28/16 (not timed) documented, .Situation: Fall . Nursing Notes: Observed transferring from chair to another chair, slid off chair seat, caught self (with) arm (no) signs of injury, at this point, denies pain . 2.) The Event Follow - Up Progress Notes dated 5/29/16 (not timed) documented, Interventions/Assessment: Awake (and) alert. Moves all extremities equal (and) well. Denies pain (at) present. (Up) in w/c, Chair alarm on (and) functioning. Plans to go out (with family) . The resident's Care Plan was not updated to include a chair alarm until 6/15/16 (refer to paragraph 'f' above). h. The Event Report dated 6/13/16 at 6:00 a.m. documented, Type of Event: Fall . Describe what occurred: I was entering room to administer meds (medications) to R (Resident). She was exiting the bathroom and fell to her knees. Assessed R, (no) signs of swelling and (no) bruising noted. (No) c/o (complaints of) pain or discomfort. Assisted R into wheelchair . Immediate or Initial Interventions: Chair Alarm and consult (with) PT (Physical Therapy) and walker per family request . Recommendations and or new interventions - Review interventions initiated at time of event to ensure appropriateness: Chair Alarm, to alert staff of attempts to rise from w/c unassisted. Function checks . The Event Investigation Report dated 6/13/16 at 6:00 a.m. documented: .Type of transfer assistance required - specify: 1 person assist. 1.) The SBAR Communication Form and Progress Note dated 6/13/16 (not timed) documented, Situation - Fall. 2.) The Event Follow-up Progress Notes dated 6/13/16 documented, Investigation / Assessment: No discoloration to either knee. (Up) sitting in w/c in D/R (dining room), denies pain nor discomfort. Chair alarm functioning properly. No (change) in ROM (range of motion) . i. The Event Report dated 8/2/16 at 3:10 p.m. documented, Type of Event: Fall . Describe what occurred: Room-mate states that 'My room-mate fell earlier'. Upon questioning res. (resident), Res states 'Yeah I fell on my knees (and) got up by myself. I'm not hurt'. Upon assessment no injuries were noted. Stated got off bed was walking to my recliner (and) fell on knees at foot of bed. (No) injuries noted. Moving all ext (extremities) (without) problems. Res noted to be in socks . Immediate or Initial Interventions: make sure alarms are in place (and) working properly, Shoes on when (up) amb (ambulating) . Follow up: Check placement (and) function of alarms (every) shift . Recommendations and / or new interventions - Review Intervention initiated at time of event to ensure appropriateness. Alarm to be checked for placement (and) function every shift frequent checks. The only new intervention documented was to ensure resident was wearing shoes when ambulating; however, there was no indication that the care planned alarms alerted staff when the resident got up to ambulate on this occasion. 1.) The SBAR Communication Form and Progress Note dated 8/2/16 at 3:10 p.m. documented, Situation: Fall, Nurses Notes: Roommate tells CNA (Certified Nursing Assistant) that this res (resident) fall. Upon questioning res states Got off bed walking to recliner and I just fell down on knees (at) foot of bed (and) got up by myself.' Denies pain. (No) injury noted. Was in sock feet. Alarm not connected. Not sure if walker was used . There was no documentation of any investigation to determine why the alarm was not connected, i.e. - whether staff forgot to place the alarm or whether the resident was able to remove the alarm herself. 2.) The Event Follow - Up Progress Notes dated 8/3/16 documented, Interventions / Assessment: In room sitting in chair (with) legs extended (and) moving legs back (and) forth, denies pain or discomfort, no (change) in ROM. No stiffness, No indication of bruising. Bed alarm in working order . There was no documentation as to whether a chair alarm was present at this time. j. The Event Report dated 8/20/16 at 5:00 p.m. documented, .Describe what occurred: Resident was seen on (left) knee (and) hand in 400 hallway. Resident was able to get up before help could get to her. Resident stated that she stumbled, caught herself (and) isn't hurting. APRN (Advanced Practice Registered Nurse) notified. Daughter notified. No visible marks on resident . She stated she just got tired (and) started to go down, caught herself (and) got back up . Immediate or Initial Interventions: Assisting resident when walking (and) ensuring proper use of walker . Recommendation and/or interventions - Review intervention initiated at time of event to ensure appropriateness: Reminder to resident to take her time and be more careful (with) ambulation. There was no indication as to whether a chair or bed alarm was sounding at this time and no documentation of any fall prevention interventions, other than reminding the cognitively impaired resident to take her time and be more careful and restating that the resident was to be assisted with ambulation and use a walker. 1.) The SBAR Communication Form and Progress Note dated for 8/20/16, not timed, documented, Situation Fall . Nurses Notes: Resident was seen on (left) knee (and) hand in hallway, no visible s/s (signs and symptoms) of distress or discomfort. Resident stated she was not in pain. 2.) The Event Follow-up Progress Notes dated 8/22/16 documented, Sitting in soft chair in room (with) walker in front of her, no c/o pain or discomfort, no (change) in ROM. No sign of discolored skin. Will cont (continue) to monitor for (changes). There was no documentation as to whether a chair alarm was in place at this time. k. The Rehab / Nursing Training Form dated 9/20/16 documented, From PT (Physical Therapy) discharged Therapy Services on 8/15/16. Plan should be initiated on 9/21/16 frequency 3x wk (3 times per week). Duration 12 weeks. Recommendations. 1. Pt (patient) to walk at least 124' (feet) (with) RW (rolling walker) and close supervision. 2. Standing leg exercises including marching heels raises hip abduction 3 x (times) 10 reps (repetitions). Precautions: Fall risk when fatigued. l. An Event Report dated 9/27/16 at 12:15 p.m. documented, .Describe what occurred: Heard fall, (no) witness, R (Resident) lying on stomach. Neuro (neurological) checks started. Able to move all extremities . Follow Up: Currently being (treated) for pneumonia, res weak will monitor closely (and) frequently check for changes . There was no documentation the resident was asked how the fall occurred, what she was doing at the time of the fall, or whether a chair or bed alarm were sounding at the time of the fall. 1.) The SBAR Communication Form and Progress Note dated 9/27/16 documented, Situation-Fall . Nursing Notes: Heard fall CNAs went running into room observed lying on floor. Stated she fell , L (left) hand. discoloration noted, able to move all extremities (without) pain. 2.) The Event Follow-Up Progress Notes documented, Intervention / Assessment 9/28/16 (Up) in bed, supine, discoloration to left hand (with) full ROM. No noted other areas of injury. No c/o pain nor discomfort . 3.) The Safety Committee Event Investigation Follow-Up Report dated 9/28/16 documented, .Describe corrective actions taken to prevent recurrence of this even: Alarm functioning properly . Recommendation and/new interventions - Review interventions at time of event to ensure appropriateness. Frequent checks, lay Resident down (after) meals (and) when she's tired, cont. (continue) Alarm, don't leave in room for extended periods of time in wheelchair. To rest more in recliner. These interventions were not added to the resident's Care Plan (refer to paragraph 'f' above). m. The Event Report dated 9/27/16 at 12:30 p.m. documented, Type of Event: fall . Description what occurred, called to room by CNA (name) responding to bed alarm. Found resident in floor beside bed. Stated more on L (left) hip, legs bent to R (right) side. No noted injuries, no c/o pain. Assisted to standing position (and) returned to bed . Describe corrective actions taken to prevent recurrence of this event: Bed Alarm functioning properly . Recommendations and/or intervention - Review intervention initiated at time of event to ensure appropriateness: Part B therapy services. Resident reminders to ask for assist when transferring self . 1.) The Event Investigation Report dated 9/27/16 documented, .Cognitive Status, Describe cognitive status before event: Slightly confused. Describe cognitive status after event, Increased confusion. 2.) The SBAR Communication Form and Progress Note dated 9/27/16 documented, Situation Fall . Nurses Notes (for additional information on the Change in Condition): Heard fall CNA's went running into room observed lying in floor. Stated she fell . (L) hand discoloration noted. Able to move all extremities. Neurological Assessment were attached. 3.). The Therapy Screening Form dated 9/28/16 documented, Fall Risk . Referred by NRSG (Nursing), Diagnoses: [REDACTED]. A Communication Form from Therapy to Nursing documented, Referral or Concern. (1) Pt (Patient) should be supervised with mobility due to low vision and poor safety awareness. (2) Recommend moving pats room closer to nurses station as pt quickly fatigues and has difficulty negotiating obstacles . n. The Event Report dated 9/29/16 at 12:00 a.m. documented, Type of Event: Fall - observed on floor . Describe what occurred: Called to rm (room) by CNA, Res (Resident) found in floor (with) Hematoma noted to L (left) eyebrow, Neuro (checks) started (and) WNL (within normal limits). Ice pack applied, intermit (intermittently). Res cont (continues) to remove ice pack . 1.) A Safety Committee Event Investigation Follow-Up Report dated 9/29/16 documented, .Summary of Event / Investigation Need for additional information - Conduct Re-enactment. Found in BR (Bathroom) (with) head under sink, hematoma to (upper) eyebrow area 3 cm (centimeters). Neuro checks begun . Describe corrective actions taken to prevent recurrence of this event: Frequent checking, assure using walker, will have therapy services to screen . Recommendations and / or new interventions - Review interventions initiated at time of event to ensure appropriateness: Low bed (with mat) . The form did not document an explanation as to how a low bed with mat would be effective to prevent further injuries related to falls in the bathroom. 2.) An Event Investigation Report dated 9/29/16 documented, .Cognitive Status: Confused (increased x 2 days), Behaviors: Turned off alarm when (up) to BR (bathroom) . There was no documentation that an evaluation was done regarding whether a different type of alarm was needed, since the resident was able to turn the alarm off independently. 3.) The SBAR Communication Form and Progress Note dated for 9/29/16 documented, Situation: .Fall . There was no documentation in the Nursing Notes section of the form. 4.) The Event Follow-up Progress Notes dated 9/29/16 documented, Therapy has been given a screen request. Hematoma to left eyebrow area, new orders for CBC (complete blood count), BMP (basic metabolic profile), H-pylori (helicobacter pylori), stool specimen, KUB (Kidney, Ureter and Bladder x-ray) for c/o (complaint of) abdominal pain. Placed on [MEDICATION NAME] 40 mg (milligrams) daily. 5.) A Communication Form dated 9/29/16 documented, Therapy to Nursing, Resident concern, Referral or Concern. 1. Pt (patient) should be supervised with mobility due to low vision and poor safety awareness. 2. Recommend moving pt's (patient's) room closer to Nursing Station as pt quickly fatigues and has difficulty negotiating obstacles. o. The Event Report dated 10/4/16 at 5:30 p.m. documented, Type of Event: Fall . Describe what occurred: Called to room per CNA. Upon assessment Res noted in front of bathroom floor sitting on L (left) hip (with) legs bent. Attempting to get up herself. (No) physical injury noted. Moving ext (without) problems. Denies pain . Bed Alarm in place but not proper placement; this alarm did not sound. Immediate or initial Interventions. In-service staff or monitor Res (and) safety equipment. Follow Up: Frequent toileting (every) 2 hours initiating program will encourage to come to DR for meals . 1.) The SBAR Communication Form and Progress Note dated 10/4/16 at 5:30 p.m. documented, Situation: Fall .Nurses Notes: Called to room per CNA. Res seated in front of bathroom floor sitting on L (left) hip (with) legs bent. Attempting to get up per self. Denies pain moving ext (extremities) (without) problem. Assist (up) x 2. Cognitive Status before event, Alert with confusion. Cognitive status after event, Alert with confusion. 2.) A Safety Committee Event Investigation Follow-Up Report dated 10/5/16 documented, .Describe corrective actions taken to prevent reoccurrence of this event: Frequent checks and toileting program (every) 2 hours . Recommendation and /or new interventions - Review intervention initiated at time of event to ensure appropriateness: Plans being made to move res closer to nurses station . This was a period of 6 days after PT documented a recommendation to move the resident to a room closer to the nurses' station. p. The Event Report dated 10/23/16 at 11:18 a.m. documented, Type of Event: Fall . Describe what occurred: R was found in the floor of her room on her coccyx. She stated that she was trying to get some popcorn off the floor (and) slipped. She stated she did not hit her head (and) that she had (no) pain . Immediate or initial Interventions: Instructed on importance of using call light. There was no documentation that any interventions were implemented, other than instructing the cognitively impaired resident to use her call light. The SBAR Communication Form and Progress Note dated 10/23/16 documented, Situation Fall . Nursing Notes: R was found in the floor of her room on her coccyx. She stated that she was trying to get some popcorn off the floor (and) slipped. She stated she did not hit her head (and) that she had (no) pain . Immediate or Initial Interventions: Instructed on importance of using call light . There was no further interventions documented on this form. q. A Physical Therapy Treatment Encounter Note, with certification dates of 10/22/16-11/20/16, documented, 11/3/16 Pt (Patient) amb (ambulated) with RW (rolling walker) 150' (feet), SBA (stand by assist) for initial 50' (feet), then required min/mod (minimal to moderate) A (assistance) secondary to Pt leaning to the R (right), pushing RW too far out in front of her, shuffling gait, while veering sideways. Pt speaking to PT (Physical Therapy), trial w/ (with) weighted 10# (10-pound) RW assessed w/160' (feet) w/ CGA/SBA (Contact/Guard Assistance / Stand-by Assistance) for initial 75' (feet), then requiring min A (assist) w/mod (with moderate) A maneuvering RW . Resident unable to maintain control of AD (assistive device). Comments: Subjective / objective LPN and CNA notified of pt's unsteadiness this date and the need for increased assistance w/ mobility. r. An Event Report dated 11/30/16 at 7:00 a.m. documented, Type of event: Fall . Describe what occurred: Res amb per walker per self on way to DR (dining room). Observed sitting on buttocks. Leaning more to R (right) side, R leg bent at knee and under L leg. Res straights R leg out (without) problem or c/o (complaint of) pain in R leg, hip (and) knee. States someone ran into me. No one around Res. Res legally blind. Cognitive status before event, Alert and confused. Cognitive Status after event, Alert and confused. Res was up against wall beside supply room . Immediate or Initial Intervention: X-ray, R knee, R hip. Sent to (Hospital name) ER (emergency room ) Behaviors . There was no documentation as to whether a chair or bed alarm were sounding in the resident's room at this time. 1.) The SBAR Communication Form and Progress Note dated 11/30/16 at 7:00 a.m. documented, Situation, Fall . Nursing Notes: Res observed sitting on buttocks more on R (right) buttocks (with) R (right) leg bent (at) knee under L leg. Moved both ext. (without) c/o (complaint of). Assist to stand x 2. Would not bear wt (weight) to R assist to wc (wheelchair). States 'someone ran into me.' No one in area. Res was on way to DR (dining room) was against wall next