Every finding on record at Heritage Hall-Blackstone

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide notice of Medicare non-coverage for two of three beneficiary protection notification resident reviews, Residents #50 and #62. The findings include: 1. For Resident #50 (R50), the facility staff failed to provide the resident and/or the responsible party with an ABN (advance beneficiary notice) to allow them to make an informed decision regarding their care. R50's last covered day of Medicare part A services was 2/28/2023. R50 was admitted to the facility on [DATE]. R50's diagnoses included but were not limited to congestive heart failure, type two diabetes mellitus and cerebral infarction. R50 remained in the facility at the time of the survey. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/17/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. On 5/16/2023 at approximately 10:00 a.m., ASM (administrative staff member) #1, provided a NOMNC (notice of Medicare Non-Coverage) for R50 signed on 2/16/2023 documenting services were ending 2/28/2023. ASM #1 stated that R50 was not provided an ABN notice. ASM #1 stated that the facility had conducted a mock survey in March of 2023 and identified a need for improvement in providing the ABN notices to residents, so they had put a plan of correction in place at that time. On 5/16/2023 at 10:31 a.m., ASM #1 provided a copy of the plan of correction put in place after the mock survey conducted 3/14/2023-3/17/2023 including a sign-in sheet documenting education provided to OSM (other staff member) #3, the business office manager, regarding ABN completion in a timely manner, informing residents of the right to appeal and how to appeal a notice of discharge. The plan was dated 3/17/2023. ASM #1 stated that this was the only staff member responsible for this task in the facility. ASM #1 stated that the date of compliance for the plan of correction was 4/14/2023. On 5/16/2023 at 1:41 p.m., an interview was conducted with OSM #3. OSM #3 stated that they were the only person in the facility responsible for providing the ABN and NOMNC to residents in the facility. OSM #3 stated that they provided residents with three days notice before their services ended. OSM #3 stated that they typed up the notices and took them to the resident and had the resident sign them if they were able to. OSM #3 stated that if the resident was not able to sign the notices themselves they had the responsible party sign the notice or notified them by telephone. OSM #3 stated that they had identified an issue with not providing the notices during the mock survey, and they had been educated on the process, and that they now knew which residents required the notices and when to provide them to the resident. OSM #3 stated that they had one resident discharged from Medicare Part A services since the date of compliance for the plan of correction on 4/14/2023 and the proper notices had been provided. Verification of the facility plan of correction was completed by staff interviews and review of the resident discharged from Medicare part A services after the plan of correction date of compliance of 4/14/2023. A review was made of the ABN and NOMNC notice provided for the other resident, Resident #136 (R136), with skilled services ending on 4/15/2023. The ABN notice was signed on 4/11/2023 and the NOMNC was signed on 4/11/2023. The resident remained in the facility. No concerns were identified. On 5/17/2023 at 12:00 p.m., ASM #5, the regional director of clinical services stated that the facility did not have a policy regarding providing ABN/NOMNC notices and that they followed the state regulations and guidelines. On 5/16/2023 at approximately 4:30 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the above concern. No further information was presented prior to exit. This was cited as past non-compliance. 2. For Resident #62 (R62), the facility staff failed to provide the resident and/or the responsible party with an ABN (advance beneficiary notice) to allow them to make an informed decision regarding their care. R62's last covered day of Medicare part A services was 1/31/2023. R62 was admitted to the facility on [DATE]. R62's diagnoses included but were not limited to cerebral infarction, hemiplegia, and congestive heart failure. R62 remained in the facility at the time of the survey. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/2/2023, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. On 5/16/2023 at approximately 10:00 a.m., ASM (administrative staff member) #1, provided a NOMNC (notice of Medicare Non-Coverage) for R62 signed 1/26/2023 documenting services ending 1/31/2023. ASM #1 stated that R62 was not provided an ABN notice. ASM #1 stated that the facility had conducted a mock survey in March of 2023 and identified a need for improvement in providing the ABN notices to residents so they had put a plan of correction in place at that time. On 5/16/2023 at 10:31 a.m., ASM #1 provided a copy of the plan of correction put in place after the mock survey conducted 3/14-3/17/2023 including a sign-in sheet documenting education provided to OSM (other staff member) #3, the business office manager, regarding ABN completion in a timely manner, informing residents of right to appeal and how to appeal notice of discharge date d 3/17/2023. ASM #1 stated that this was the only staff member responsible for this task in the facility. ASM #1 stated that the date of compliance for the plan of correction was 4/14/2023. On 5/16/2023 at 1:41 p.m., an interview was conducted with OSM #3. OSM #3 stated that they were the only person in the facility responsible for providing the ABN and NOMNC to residents in the facility. OSM #3 stated that they provided residents with three days notice before their services ended. OSM #3 stated that they typed up the notices and took them to the resident and had the resident sign them if they were able to. OSM #3 stated that if the resident was not able to sign the notices themselves they had the responsible party sign the notice or notified them by telephone. OSM #3 stated that they had identified an issue with not providing the notices during the mock survey, and they had been educated on the process, and that they now knew which residents required the notices and when to provide them to the resident. OSM #3 stated that they had one resident discharged from Medicare Part A services since the date of compliance for the plan of correction on 4/14/2023 and the proper notices had been provided. Verification of the facility plan of correction was completed by staff interviews and review of the resident discharged from Medicare part A services after the plan of correction date of compliance of 4/14/2023. A review was made of the ABN and NOMNC notice provided for the other Resident #136 (R136) with skilled services ending on 4/15/2023. The ABN notice was signed on 4/11/2023 and the NOMNC was signed on 4/11/2023. The resident remained in the facility. No concerns were identified. On 5/16/2023 at approximately 4:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the above concern. No further information was presented prior to exit. This was cited as past non-compliance.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence the monthly drug regimen reviews for one of 48 residents, Resident #66. The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: CVA (cerebral vascular accident), dysphagia, anxiety disorder, cognitive communication deficit, unspecified dementia without behavior/psychosis/mood/anxiety behaviors. A review of the comprehensive care plan dated 3/20/23, which revealed, PROBLEM/NEED: Psychotropic drug use APPROACHES: evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. Monitor pharmacists drug regime review for identification of potential drug interactions. Monitor resident for signs of tremor and document. Report onset of increase to physician. A review of the physician's orders dated 3/22/23, revealed, Buspirone 5 mg (milligram) tablet, give one tablet by mouth at bedtime. Mirtazapine 15 mg take one tablet by mouth at bedtime. A review of the MRR (monthly regimen reviews) for Resident #66, evidenced a review in June, July, August, September and November 2022; February and May 2023 were present. There were no MRRs in October and December 2022; January, March and April 2023. Five of 12 MRRs were missing. An interview was conducted on 5/16/23 at 4:55 PM with ASM (administrative staff member) #4, the regional nurse consultant. When asked if there were MRRs for Resident #66, ASM #4 stated, the pharmacist is having some IT (information technology) issues and we have not been able to obtain them. When asked if these IT issues had existed for months, ASM #4 stated, No, it has been the last couple of hours since we have asked for them. An interview was conducted 5/16/23 at 5:00 PM with ASM #2, the director of nursing, who stated, We are looking for the rest of her MRRs. The pharmacist emails me a monthly report that includes all the residents that have no recommendations and who has recommendations. The pharmacist writes on note specifying the recommendations. An interview was conducted on 5/17/23 at 9:41 AM with OSM (other staff member) #4, the pharmacist. When asked about the process for completing medication regimen reviews for the residents, OSM #4 stated, We are on site every month, it does occur on site every month. Upon admission we will perform the MRR off site. When asked about the five of 12 missing MRR's, OSM #4 stated, I am still trying to figure out. I moved from the previous pharmacy company to this one to stay with the residents. I follow my customer. This is a new system for me. For some reason she [Resident #66] dropped off. I am having IT look into it. The resident was not uploading to my clinical software. When asked the recommendations for May 16, 2023, OSM #4 stated, The antidepressant and antianxiety medications are in compliance and I recommended we look at a GDR (gradual dose reduction). On 5/17/23 at 10:30 AM, ASM (administrative staff member) #1, the administrator was made aware of the findings. A review of the facility's Medication Regimen Review policy dated 9/18, revealed, Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the IDT (interdisciplinary team), including the resident, their family, and/or resident representative. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a medication error rate less than 5% for three of five residents in the medication administration observation, Residents #76, #84 and #132. The findings include: 1. For Resident #76 (R76), the facility staff failed to administer Lasix (1) as ordered by the physician. On 5/16/2023 at 8:09 a.m. an observation was made of LPN (licensed practical nurse) #4 administering medications to Resident #76. LPN #4 poured the following medications: Senna 8.6 MG (milligram) tablet (1) - one tablet Vitamin B12 1000 MG (2) - one tablet Calcium Citrate 250 MG (3) - one tablet Metoprolol 25 MG tablet (4) Nitrofurantoin 50 MG capsule (5) - one capsule Miralax 17 GM (grams) (6) mixed in 120 ml (milliliters) of water. Review of the physician orders documented the above medication orders. There was a physician order for Lasix 20 MG Tablet (7), give 1 tab (tablet) PO (by mouth) QD (every day) Dx (diagnosis) CHF (congestive heart failure). An interview was conducted with LPN #4 on 5/16/2023 at 10:29 a.m. When asked if she gave R76 Lasix during the morning medication administration, LPN #4 pulled the cards holding the medications out of the medication cart. She looked through the cards of medications and there was no card for Lasix. LPN #4 stated, I guess I didn't give it. When asked should she have given it, LPN #4 stated, yes. The facility policy, Medication Administration documented in part, Medications shall be administered in a safe and timely manner and as prescribed. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse consultant, were made aware of the above findings on 5/16/2023 at 4:40 p.m. No further information was provided prior to exit References: (1) Senna is used to treat constipation. This information was obtained from the following website: https://medlineplus.gov/druginfo/natural/652.html (2) Vitamin B12 is a supplement. This information was obtained from the following website: https://ods.od.nih.gov/factsheets/VitaminB12-Consumer/ (3) Calcium is a mineral your body needs to build and maintain strong bones and to carry out many important functions. Calcium is the most abundant mineral in the body. This information was obtained from the following website: https://ods.od.nih.gov/factsheets/Calcium-Consumer/ (4) Metoprolol is used alone or in combination with other medications to treat high blood pressure. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682864.html (5) Nitrofurantoin is used to treat urinary tract infections. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682291.html (6) Polyethylene glycol (Miralax) 3350 is used to treat occasional constipation. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a603032.html (7) Furosemide (Lasix) is used to treat edema [fluid retention; excess fluid held in body tissues] caused by various medical problems, including heart, kidney, and liver disease. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682858.html 31753 2. For Resident #84 (R84), RN (registered nurse) #4 failed to administer the physician prescribed medication calcium 500 mg (milligrams)/vitamin D 5 mcg (micrograms) on 5/16/23. RN #4 administered 25 mcg of vitamin D rather than the prescribed dosage. A review of R84's clinical record revealed a physician's order dated 3/24/23 for calcium 500mg/vitamin D 5mcg once a day. On 5/16/23 at 8:03 a.m., RN #4 was observed preparing and administering medications to R84. Instead of administering calcium 500mg/vitamin D 5mcg, RN #4 administered vitamin D 25 mcg. On 5/16/23 at 2:11 p.m., an interview was conducted with RN #4. RN #4 was made aware of the above observation. RN #4 presented R84's medication administration record that documented the physician's order for calcium 500mg/5 mcg vitamin D and stated she didn't know what she gave. On 5/16/23 at 4:35 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the above concern. 3. For Resident #132 (R132), RN (registered nurse) #4 failed to administer the correct amount of the physician prescribed medication Senna (used to treat constipation). Instead of administering two tablets of Senna to R132, RN #4 only administered one tablet. A review of R132's clinical record revealed a physician's order dated 3/27/23 for Senna 8.6 mg (milligrams)- two tablets twice a day. On 5/16/23 at 7:49 a.m., RN #4 was observed preparing and administering medications to R132. RN #4 administered one tablet of Senna to the resident. On 5/16/23 at 2:00 p.m., an interview was conducted with RN #4. RN #4 reviewed R132's physician's order for two tablets of Senna and stated she only gave one tablet. On 5/16/23 at 4:35 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the above concern.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to assess a resident for self-administration of medications, prior to leaving medication on the over bed table, for one of 48 residents in the survey sample, Resident #76. The findings include: The nurse administered morning medications to Resident #76 (R76) then left the cup with Miralax (used to treat constipation) (1) in it, on the overbed table and left the room. On 5/16/2023 at 8:09 a.m. LPN (licensed practical nurse) #4 was observed administering medications to R76. LPN #4 mixed the Miralax in a cup of water and took it into R76's room with the other medications. After administering the other medications, LPN #4 placed the cup of Miralax on the over bed table, then left the room. Observation was made on 5/16/2023 at 8:45 a.m. of R76's room. The cup with the Miralax was still on the overbed table. On the most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 4/13/2023, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. Review of the clinical record failed to evidence a physician order for self-administering medications or an assessment for the self-administering of medications. An interview was conducted with LPN #4 on 5/16/2023 at 10:29 a.m. When asked if she left medication on the overbed table for R76. LPN #4 paused and then stated, yes, the Miralax. LPN #4 stated she is not supposed to do that. When asked if she had returned to R76's room since then, to see if the resident had drank the Miralax, LPN #4 stated, No, I haven't had a chance. The facility policy, Administering Medications documented in part, Medications shall be administered in a safe and timely manner, and as prescribed 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse consultant, were made aware of the above findings on 5/16/2023 at 4:40 p.m. No further information was provided prior to exit

Based on observation, staff interview, and facility document review, the facility staff failed to implement the care plan for two of 48 residents in the survey sample, Residents #20 and #66. The findings include: 1. For Resident #20 (R20), the facility staff failed to implement the care plan to apply hand devices to prevent further contractures. On the following dates and times, R20 was observed in bed. R20's left and right hands were contracted. At all of these observations, the resident was not wearing hand devices/splints: 5/15/23 at 12:20 p.m. and 2:32 p.m.; and 5/16/23 at 8:57 a.m. and 10:46 a.m. A review of R20's physician orders revealed an order dated 2/9/23 which read: RNP (restorative nursing program) Splinting program seven days a week. A review of R20's care plan dated 8/27/20 revealed, in part: RNP splinting program seven days a week. A restorative nursing aide was not available for interview during the survey. On 5/16/23 at 4:30 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of the concern regarding Resident #20 not having hand splints in place. On 5/16/23 at 3:05 p.m., RNs (registered nurses) #1 and #2, the MDS (minimum data set) coordinators, were interviewed. RN #1 stated the purpose of a care plan is to show the goals for a resident, and to show the staff what the plan of care is. RN #2 stated the care plan tells the staff what they should be doing for a resident, and what they should be watching for. She stated the care plan is a resource for staff if they are unfamiliar with a particular resident's needs. On 5/17/23 at 10:29 a.m., LPN (licensed practical nurse) #6 stated the purpose of the care plan is for everyone to know what level of care should be given to each resident. She stated the nurse is responsible for making sure the care plan interventions are implemented. A review of the facility policy, Care Plans, Comprehensive Person-Centered, revealed, in part: The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The comprehensive, person-centered care plan will .aid in preventing or reducing decline in the resident's functional status and/or functional levels. No further information was provided prior to exit. 42183 2. For Resident #66, the facility staff failed to implement the comprehensive care plan to monitor the pharmacist's drug regime reviews for identification of potential drug interactions. Resident #66 was admitted to the facility with diagnoses that included but were not limited to: CVA (cerebral vascular accident), anxiety disorder, cognitive communication deficit, and unspecified dementia without behavior/psychosis/mood/anxiety behaviors. A review of the comprehensive care plan dated 3/20/23, which revealed, PROBLEM/NEED: Psychotropic drug use APPROACHES: evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. Monitor pharmacists drug regime review for identification of potential drug interactions. Monitor resident for signs of tremor and document. Report onset of increase to physician. A review of the physician's orders dated 3/22/23 included, Buspirone 5 mg (milligram) tablet give one tablet by mouth at bedtime (1), and Mirtazapine 15 mg take one tablet by mouth at bedtime (2) . A review of the MRR (monthly regimen reviews) for Resident #66, evidenced June, July, August, September and November 2022; February and May 2023 were present. Missing MRRs were October, December 2022; January, March and April 2023. Five of 12 MRRs were missing. An interview was conducted on 5/16/23 at 3:05 PM, with RNs (registered nurses) #1 and #2, MDS (minimum data set) coordinators, were interviewed. RN #1 stated the purpose of a care plan is to show the goals for a resident, and to show the staff what the plan of care is. RN #2 stated the care plan tells the staff what they should be doing for a resident, and what they should be watching for. She stated the care plan is a resource for staff if they are unfamiliar with a particular resident's needs. An interview was conducted on 5/17/23 at 9:30 AM, with ASM (administrative staff member) #5, the regional director of clinical services. When asked if the care plan includes approach of Monitor pharmacists drug regime review for identification of potential drug interactions and five of 12 MRRs were missing, was the care plan being followed, ASM #5 stated, no, it is not being followed. On 5/17/23 at 10:30 AM, ASM (administrative staff member) #1, the administrator was made aware of the findings. No further information was provided prior to exit. References: (1) Buspirone is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety. Buspirone is in a class of medications called anxiolytics. It works by changing the amounts of certain natural substances in the brain. https://medlineplus.gov/druginfo/meds/a688005.html. (2) Mirtazapine is used to treat depression. Mirtazapine is in a class of medications called antidepressants. It works by increasing certain types of activity in the brain to maintain mental balance. https://medlineplus.gov/druginfo/meds/a697009.html

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the administration of medications, for one of 48 residents in the survey sample, Resident #76. The findings include: The nurse administered morning medications to Resident #76 (R76) then left the cup with Miralax (used to treat constipation) (1) in it, on the overbed table and left the room. On 5/16/2023 at 8:09 a.m. LPN (licensed practical nurse) #4 was observed administering medications to R76. LPN #4 mixed the Miralax in a cup of water and took it into R76's room with the other medications. After administering the other medications, LPN #4 placed the cup of Miralax on the over bed table, then left the room. Observation was made on 5/16/2023 at 8:45 a.m. of R76's room. The cup with the Miralax was still on the overbed table. On the most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 4/13/2023, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. Review of the clinical record failed to evidence a physician order for self-administering medications or an assessment for the self-administering of medications. The facility policy, Administering Medications documented in part, Medications shall be administered in a safe and timely manner, and as prescribed 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse consultant, were made aware of the above findings on 5/16/2023 at 4:40 p.m. No further information was provided prior to exit

Based on observation, staff interview, and facility document review, the facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion for bilateral hand contractures for one of 48 residents in the survey sample, Resident #20. The findings include: For Resident #20 (R20), the facility staff failed to apply hand devices/splints to prevent further contractures. On the following dates and times, R20 was observed in bed. R20's left and right hands were contracted. At all of these observations, the resident was not wearing hand devices: 5/15/23 at 12:20 p.m. and 2:32 p.m.; and 5/16/23 at 8:57 a.m. and 10:46 a.m. A review of R20's physician orders revealed an order dated 2/9/23 which read: RNP (restorative nursing program) Splinting program seven days a week. A review of R20's care plan dated 8/27/20 revealed, in part: RNP splinting program seven days a week. A restorative nursing aide was not available for interview during the survey. On 5/16/23 at 4:30 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. On 5/17/23 at 9:30 a.m., OSM (other staff member) #5, a physical therapy assistant and the rehab program manager, was interviewed. She stated R20 has contractures has contractures in both hands. She stated: The contractures are well-maintained through the hand splints. She stated the therapy staff screens each resident every quarter. She stated R20's hand splints are actually palm guards. She stated for R20, the palm guards, which ordinarily are put in place to prevent skin breakdown, actually serve a dual role of hand splint and skin protectant. She stated the palm guards are the least restrictive method to prevent R20's contractures from worsening. She stated the palm guards serve to maintain hand joint integrity, and prevent the pain and possible skin breakdown that come from worsening contractures. She stated the resident should be wearing the palm guards for most of the day and evening, and should be removed overnight. On 5/17/23 at 10:29 a.m., LPN (licensed practical nurse) #6 stated she finds out in report from the previous nurse or in the resident's orders that a resident needs a hand splint. She stated if a resident is new to the unit, the therapy staff provides instructions on how to apply the splints. She stated the nurse is ultimately responsible for applying the hand splint. She stated the hand splints are needed to keep the resident's contractures from progressing. On 5/17/23 at 10:45 a.m., CNA (certified nursing assistant) #4 was interviewed. She stated the nurse informs her of residents who need to wear hand splints, and it is her job to make sure the splints are applied. A review of the facility policy, Resident Mobility and Range of Motion, revealed, in part: Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM (range of motion) .Interventions may include .the provision of necessary equipment. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to implement interventions to prevent an injury from a fall, for one of 48 residents in the survey sample, Resident #342. The findings include: For Resident #342 (R342), the facility staff failed to place fall mats beside the resident's bed. On the following dates and times, R342 was observed in bed. Fall mats were not visible on the floor beside the resident's bed on 5/15/23 at 12:04 p.m. and 2:25 p.m., and on 5/16/23 at 8:53 a.m. and 10:22 a.m. On 5/15/23 at 2:25 p.m., R342 was interviewed. The resident stated the facility staff has never put fall mats beside the bed. A review of R342's clinical record revealed the resident was admitted to the facility on [DATE]. A review of R342's orders revealed the following order, dated 5/11/23: Fall mats to floor while resident in bed. Check placement q (every) shift. The resident's comprehensive assessment and care plan had not yet been developed. On 5/17/23 at 10:29 a.m., LPN (licensed practical nurse) #6 was interviewed. She stated fall mats are ordered for all newly admitted residents until the facility can complete the comprehensive assessment. She stated the nurse is responsible for making sure the fall mats are implemented. On 5/17/23 at 10:45 a.m., CNA (certified nursing assistant) #4 was interviewed. She stated the nurse informs her of residents who need fall mats, and it is her job to make sure the fall mats are down beside the resident's bed when the resident is in the bed. She stated all newly admitted residents have orders for fall mats. On 5/17/23 at 10:56 a.m., ASM (administrative staff member) #2, the director of nursing, was informed of these concerns. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed for one of four residents in the survey sample, to implement the abuse policy for reporting abuse, Resident #1. The findings include: The facility failed to implement their abuse policy to report occurrences according to regulations. A review of the facility grievance form, dated 5/2/22, revealed Detail of complaint/grievance: Resident claims that he was assaulted with a paper towel while being changed and cleaned. Resident claims CNA (certified nursing assistant) inserted paper towels in his rectum while she was cleaning him. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: CAD (coronary artery disease), anemia, non-traumatic brain dysfunction, non-Alzheimer's dementia, COPD (chronic obstructive pulmonary disease) and diabetes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/6/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing and hygiene and limited assistance for eating. A review of the comprehensive care plan with a date of 1/22/21 and revision date of 8/29/22, revealed, PROBLEM /NEED: Potential for injury for diagnosis of suicidal ideations, anxiety disorder, psychosis, dementia with behavioral disturbances, depression. Makes paranoid accusations against staff. APPROACHES: Monitor and document behavior as needed. Report increased negative behavior to the physician. Maintain resident environment free of clutter and safety hazards. The facility's policy titled Abuse, Neglect and Exploitation dated 10/24/22, included: Reporting/Response: the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and not result in serious bodily injury. An interview was conducted on 11/16/22 at 11:10 AM, with OSM (other staff member) #1, the director of social services. When asked who followed up with Resident #1 regarding his allegation of sexual assault, OSM #1 stated, On Sunday (5/1/22), I talked with the nursing supervisor, who told me what the resident stated. She gave me her statement in writing. I came in on Monday (5/2/22), talked with the resident and he told me the story, the CNA was caring for him, she was assigned to him and she was cleaning him and he felt like he was sexually assaulted with her finger. His perception was that he was sexually assaulted. I did my investigation with the DON (director of nursing), we got written statements and had the NP (nurse practitioner) do an actual physical assessment. Later in the day was briefed that they could not prove the allegation. The DON said nursing will handle this. When asks who reports allegations of abuse, OSM #1 stated, The administrator or the DON report it to the state, I do not do this. An interview was conducted on 11/16/22 at 11:30 AM, with RN (registered nurse) #2, the infection preventionist. When asked her role, RN #2 stated, At the time of this event, I was the nursing supervisor on the weekend. RN #2 was asked to read and verify the statement she provided to OSM #1. RN #2 verified statement. When asked to detail the events, RN #2 stated, The resident stated this happened on Friday (4/29/22) evening and reported it to me on Sunday (5/1/22) at 11:54 AM. I had not heard anything in report nor had the resident told me this before. I assessed his rectal area, did not see any broken skin, no redness or any abnormalities. The resident was calm when I talked with him and had no other concerns. I informed the DON on Sunday. When asked if she files reports to agencies related to allegations of abuse, RN #2 stated, No, I follow my chain of command, inform the DON and administrator. Normally one of them will report. I do not report outside of the facility. An interview was conducted on 11/16/22 at 12:15 PM, with ASM (administrative staff member) #1, the administrator. When asked who was responsible to report allegations of abuse, ASM #1 stated, At that time it was the DON's responsibility to report to VDH-OLC (Virginia Department of Health-Office Licensure Certification) and others. I do not see where we sent an initial or final FRI (facility reported incident) but will look again. ASM #1 stated the policy states, reporting within 2 hours of allegation of abuse. The director of nursing did not report because she felt that after the investigation, the allegation was not substantiated, there was no physical evidence of abuse and the resident's story was not matching up. On 11/16/22 at 12:46 PM, ASM #1 stated, There are no records of a FRI being sent to your office either initially or final after investigation. On 11/16/21 at 12:50 PM, ASM #1, was made aware of the finding. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to report an allegation of abuse in a timely manner to the State Agency for one of four residents in the survey sample, Resident #1. The findings include: The facility failed to report an allegation of abuse to the State Agency. A review of the facility grievance form, dated 5/2/22, revealed Detail of complaint/grievance: Resident claims that he was assaulted with a paper towel while being changed and cleaned. Resident claims CNA (certified nursing assistant) inserted paper towels in his rectum while she was cleaning him. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: CAD (coronary artery disease), anemia, non-traumatic brain dysfunction, non-Alzheimer's dementia, COPD (chronic obstructive pulmonary disease) and diabetes. The facility's policy titled Abuse, Neglect and Exploitation dated 10/24/22, revealed, Reporting/Response: the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and not result in serious bodily injury. An interview was conducted on 11/16/22 at 11:10 AM, with OSM (other staff member) #1, the director of social services. When asked who followed up with Resident #1 regarding his allegation of sexual assault, OSM #1 stated, On Sunday (5/1/22), I talked with the nursing supervisor, who told me what the resident stated. She gave me her statement in writing. I came in on Monday (5/2/22), talked with the resident and he told me the story, the CNA was caring for him, she was assigned to him and she was cleaning him and he felt like he was sexually assaulted with her finger. His perception was that he was sexually assaulted. I did my investigation with the DON (director of nursing), we got written statements and had the NP (nurse practitioner) do any actual physical assessment. Later in the day was briefed that they could not prove the allegation. OSM #1 stated the DON said nursing will handle this. When asked who reports allegations of abuse, OSM #1 stated, The administrator or the DON report it to the state, I do not do this. An interview was conducted on 11/16/22 at 11:30 AM, with RN (registered nurse) #2, the infection preventionist. When asked her role, RN #2 stated, At the time of this event, I was the nursing supervisor on the weekend. RN #2 was asked to read and verify the statement she provided to OSM #1. RN #2 verified statement. When asked to detail the events, RN #2 stated, The resident stated this happened on Friday (4/29/22) evening and reported it to me on Sunday (5/1/22) at 11:54 AM. I had not heard anything in report nor had the resident told me this before. I assessed his rectal area, did not see any broken skin, no redness or any abnormalities. The resident was calm when I talked with him and had no other concerns. I informed the DON on Sunday. When asked if she files reports to state agencies related to allegations of abuse, RN #2 stated, No, I follow my chain of command, inform the DON and administrator. Normally one of them will report. I do not report outside of the facility. An interview was conducted on 11/16/22 at 12:15 PM, with ASM (administrative staff member) #1, the administrator. When asked who was responsible to report allegations of abuse, ASM #1 stated, At that time it was the DON's responsibility to report to VDH-OLC (Virginia Department of Health-Office Licensure Certification) and others. I do not see where we sent an initial or final FRI (facility reported incident) but will look again. ASM #1 stated, the policy states, reporting within 2 hours of allegation of abuse. The director of nursing did not report because she felt that after the investigation, the allegation was not substantiated, there was no physical evidence of abuse and the resident's story was not matching up. On 11/16/22 at 12:46 PM, ASM #1 stated, There are no records of an FRI being sent to your office either initially or final after investigation. No further information was provided prior to exit.

Based on observation, staff interview and facility document review it was determined the facility staff failed to secure Medications in a safe and secure manner according to professional standards in three of three medication carts, (Wing 100-medication cart-two, Wing 200-medication cart-one and Wing 200-medication cart-two). The findings include: One whole pill and two half-loose unidentified pills were observed in the second drawer of the Wing 100-medication cart-two. Three half unidentified pills were observed in the second drawer of the left side of Wing 200-medication cart-one and an opened bottle of pills without a cap was observed in the third drawer on the right side of Wing 200-medication cart-one. One whole unidentified pill was observed in the second drawer of Wing 200-medication cart-two. On 11/16/21 at approximately 2:50 PM, an observation of Wing-200 medication cart-one was conducted with LPN (licensed practical nurse) #3. Observation inside the drawers of Wing-200 medication cart-one revealed the following: In drawer two on the left side of cart: three half loose unidentified pills. In drawer three on the right side of cart: One large bottle (capacity to hold 1000 tablets) of [MEDICATION(S)] ([MEDICATION(S)]) (1) opened with no cap. On 11/16/21 at approximately 3:00 PM, an observation of Wing-200 medication cart-two was conducted with LPN #4. Observation inside the drawer of Wing-200 medication cart-two revealed in drawer two on the left side of cart: one whole loose unidentified pill. On 11/16/21 at approximately 3:10 PM, an observation of Wing-100 medication cart-two was conducted with LPN #5. Observation inside the drawer of Wing 100-medication cart-two revealed in drawer two on the left side of cart: two half loose unidentified pills. The loose pills in each drawer above were observed located behind the medication cards stored in each drawer. When asked about the loose medications in the drawers, LPN #3 stated, There are so many cards in the drawer that sometimes the pills pop out of the medication cards, that is the problem with the cards. An interview was conducted on 11/16/21 at 2:50 PM with LPN #3. When asked about the opened bottle of pills in the drawer, LPN #3 stated, Well I know the cap was here. I just took it off when I was giving the medications. LPN #3 was observed placing the cap that was in the drawer back on the open bottle of [MEDICATION(S)]. An interview was conducted on 11/16/21 at 3:15 PM with LPN #5. When asked about the loose unidentified pills in the drawer, LPN #5 stated, We give a lot of meds here on the skilled side and there is a lot of medication cards for each resident. The drawer gets full, we are constantly pushing the cards back and forth, and we administer medications. That is why the pills sometimes pop out. I will dispose of those pills. On 11/16/21 at 5:15 PM, when asked what the standard of practice the facility followed, ASM (administrative staff member) #3, the director of nursing stated, We follow Lippincott. On 11/16/21 at 5:18 PM, ASM #1, the administrator, ASM #2, the assistant administrator, ASM #3, the director of nursing, ASM #4, the administrator of a sister facility and ASM #5, the regional nurse consultant were informed of the above findings. According to the facility's Storage of Medications policy, dated November 2020, which documents in part, The facility stores all drugs and biologicals in a safe, secure and orderly manner. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. No further information was provided prior to exit. References: (1) 2019 Lippincott Pocket Drug Guide for Nurses, Wolters, Kluwer, page 444. (2) Lippincott Nursing Procedures, 8th edition, Wolters, Kluwer, page 556.

Based on observation, staff interview and facility document review, it was determined that facility staff failed to store, and prepare food in in accordance with professional standards for food service safety. Facility staff were observed drying clean dishes using a cloth and paper towels and a fan with coated with gray dust and lint on the front and back blade guards was found blowing air over the area where dishes were washed and racked to dry. The findings include: On 11/16/2021 at approximately 9:35 a.m., an observation of the facility's dish room revealed OSM [other staff member] # 2, dietary aide removing and wiping dry clean trays, plates from the dishwashing racks on the clean dish line. OSM #2 then stacked the trays on top of each other on a ladder rack and stacked the dishes together, placing them in the dish storage rack. Observation of the wall behind the clean dish line revealed an 18 inch fan mounted on the wall, above and blowing on the clean trays, plates and silverware. On 11/16/2021 at approximately 9:45 a.m., an observation of the procedure described above was conducted with OSM # 1, dietary director. When asked about the drying procedure OSM # 1, stopped OSM # 2 from drying, provided them with a roll of paper toweling and informed them to use the One towel procedure. When asked to describe the One towel procedure OSM # 1 stated that they were to use one piece of paper towel for one piece of dish ware each. OSM # 1 was then asked to turn off the fan above the clean dish line. Observation of the fan when it stopped, revealed the fan blades, and the front and back blade guards coated with grey dust and lint. When asked about the fan, OSM # 1 stated that it helped dry the dishes. When asked who was responsible for cleaning the fan and how often it was done OSM # 1 stated that maintenance cleaned the fan. On 11/16/2021 at 10:15 an interview was conducted with OSM # 2, dietary aide. When asked how long they had been working in the dish room and who trained them, OSM # 2 stated that they had started two months ago and was trained by other staff members who worked in the dish room. When informed of the observation of them drying plates and trays with a cloth when the dishes came out dish washer, OSM # 2 stated, I use one cloth for the dishes and another one to dry the trays. When asked about the One towel procedure OSM # 2 stated that they did not know about it until OSM # 1 showed them. When asked about the fan, OSM # 2 stated that it helped dry off the excess water from the dishes and trays. On 11/16/2021 at approximately 2:10 p.m., an interview was conducted with OSM # 3, maintenance director. When asked if they were responsible for cleaning the wall mounted fan in the facility's dish room, OSM # 3 stated that it was not a part of the routine maintenance schedule but that they [maintenance department] would clean the fan when the kitchen asked. OSM # 3 further stated that if they did repairs on the fan they would clean it at that time. On 11/16/2021 at approximately 3:00 p.m., an interview was conducted with OSM # 1. When asked to describe the correct procedure for drying food trays and dishes after being washed, OSM # 1 stated, They should be air dried. When asked why they needed to be air dried, OSM # 1 stated, It doesn't harbor bacteria. When asked to describe the procedure for cleaning the wall mounted fan located in the dish room, OSM # 1 stated, We don't have a regular schedule. Maintenance will come in and clean when we call them. The facility's policy American Healthcare Dietary Policy and Procedural Manual documented in part, XII. Dishwashing. Procedure: 7. Allow clean dishes to air dry completely before storing. FDA Food Code (U.S. Food and Drug Administartion -2017): Drying 4-901.11 Equipment and Utensils, Air-Drying Required: Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry. On 11/16/2021 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, assistant administrator, ASM # 3, director of nursing, ASM # 4, administrator of sister facility and ASM # 5, nurse consultant, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to maintain an accurate clinical record for one of 44 residents in the survey sample, Resident # 106. The facility staff documented on Resident # 106's November 2021 eTAR [electronic treatment administration record] the use of a PICO wound vac [vacuum] [1] that was discontinued on 11/12/2021. The findings include: Resident # 106 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 106's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/25/2021, coded Resident # 106 as scoring a 3 [three] on the brief interview for mental status (BIMS) of a score of 0 - 15, 3 [three] - being severely impaired of cognition for making daily decisions. The Wound Evaluation & Management Summary for Resident # 106 dated, 11/12/2021 documented in part, Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] The Physician's Telephone Order for Resident # 106 dated 11/15/21 documented, Cleanse wound to R [right] hip with hibiscus wipe with dampened 4x4 [four by four] gauze, pack wound with black foam. Apply negative pressure therapy run continuous at 120 mmHg [millimeters of mercury]. Change dressing Tues [Tuesday], Friday and PRN [as needed]. The comprehensive care plan for Resident # 106 dated 07/02/2021 documented in part, Problem/Need: Infection/Wound to R [right] Hip. At risk for pain, odor, and infection due to right hip wound and comorbidities. Under Approaches it documented in part, 11/15/21 New wound care order Negative pressure therapy continuously @ [at] 120 mmHg [millimeter of mercury] per order. The eTAR [electronic treatment administration record] dated November 2021 documented, Check function of PICO vac [vacuum] to R [right] hip. If you have Any concerns or questions please reach out to wound nurse for assistance. Discontinue Date: 11/15/2021. Further review of the eTAR revealed check marks on 11/12/21 at 6:30 a.m., 2:30 p.m. and at 10:30 p.m., on 11/13/21 at at 6:30 a.m., 2:30 p.m. and at 10:30 p.m., on 11/14/21 at 6:30 a.m., 2:30 p.m. and at 10:30 p.m. and on 11/15/21 at 6:30 a.m., 2:30 p.m. and at 10:30 p.m On 11/17/2021 at 8:09 a.m., an interview was conducted with LPN [licensed practical nurse] # 2, wound nurse. When asked when the wound vac was started for Resident # 106, LPN # 2 stated that Resident # 106 had the negative wound vac on 11/12/2021. LPN #2 stated the PICO vac [3] was discontinued on the 11/12/2021. After reviewing the physician's telephone order for Resident # 106's use of the wound vac as listed above, LPN # 2 was asked why the order was dated 11/15/2021 when they stated that the wound vac started on 11/12/2021. LPN # 2 stated, The order was not written until 11/15/2021. When asked who was responsible for transcribing the order LPN # 2 stated, I responsible for obtaining the order. After reviewing Resident # 106's eTAR dated November 2021 for the dates list above, LPN # 2 was asked if the documentation was correct or accurate. LPN # 2 stated that the eTAR was not accurate for the dates listed above due to the fact that the PICO was not in use on those dates. On 11/17/2021 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, assistant administrator, ASM # 3, director of nursing, ASM # 4, administrator of sister facility and ASM # 5, nurse consultant, were made aware of the above findings. No further information was provided prior to exit. References: [1] The PICO* patient/population, intervention, comparison and outcomes] Single Use Negative Pressure Wound Therapy System is indicated for acute and chronic wounds and closed surgical incisions with low to moderate levels of exudate. This single use system is canister-free with a wear time of 7 to 14 days. Approved for both hospital and home care settings. This information was obtained from the website: https://www.woundsource.com/product/pico-single-use-negative-pressure-wound-therapy-system. [2] A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notification of a transfer to the ombudsman for one of 44 residents in the survey sample, Resident #76. The facility failed to notify the ombudsman of Resident #76's transfer to the hospital on 7/27/21. The findings include: Resident #76 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/7/21, Resident #76 was coded as being severely cognitively impaired for making daily decisions, having scored six out of 15 on the BIMS (brief interview for mental status). A review of Resident #76's clinical record revealed the following progress note written on 7/27/21 at 1:20 p.m.: CNA (certified nursing assistant) came to this nurse to report resident coughing up blood. CNA was making rounds when resident yelled out 'someone help me.' Upon entering resident's room, nurse witnessed resident coughing up copious amounts of bright red blood and [MEDICATION(S)] mixture .Vital signs were taken .Resident nodded yes as to rationale for being sent out to hospital. RP (responsible party) made aware. Resident was transported via stretcher .RP was offered bed hold, which she refused. The resident did not return to the facility until 8/6/21. Further review of Resident #76's clinical record failed to reveal evidence that the ombudsman was notified of the resident's discharge to the hospital on 7/27/21. On 11/16/21 at 5:19 p.m., ASM (administrative staff member) #1, the administrator, ASM #4, the administrator of a sister facility, ASM #5, the nurse consultant, and ASM #3, the director of nursing, were informed of these concerns. On 11/17/21 at 8:36 a.m., ASM #1 was interviewed. When asked who is responsible for notifying the ombudsman when a resident is discharged to the hospital, he stated the social worker is responsible for this. ASM #1 stated the social worker at the time of Resident #76's discharge is no longer employed at the facility. ASM #1 stated the social worker ordinarily keeps a binder with all the ombudsman notifications in it, but the paper for Resident #76's discharge on 7/27/21 could not be located. A review of the facility policy, Transfer or Discharge Notice, revealed, in part: A resident and/or his or her representative (sponsor) will be given a thirty (30)-day advance notice of an impending transfer or discharge from the facility. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge .The resident and/or representative (sponsor) will be notified in writing .a copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a comfortable, homelike environment for one of 44 residents in the survey sample, Resident #21. The facility staff failed to maintain Resident #21's wheelchair armrests in good repair. The plastic covering on the armrests was torn and cloth was exposed. The findings include: Resident #21 was admitted to the facility on [DATE]. Resident #21's diagnoses included but were not limited to diabetes, major depressive disorder and convulsions. Resident #21's annual minimum data set with an assessment reference date of 8/23/21, coded the resident's cognition as moderately impaired. On 11/15/21 at 2:01 p.m. and 11/16/21 at 7:59 a.m., observation of Resident #21 was conducted. The resident was sitting in a wheelchair. The plastic covering on both wheelchair armrests was torn with cloth exposed. On 11/16/21 at 2:07 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated the 11:00 p.m. to 7:00 a.m. CNAs are responsible for washing wheelchairs so she thought they would report torn wheelchair armrests. CNA #2 further stated if staff sees torn areas on wheelchair armrests then staff is supposed to notify maintenance with a work order in the computer system. On 11/16/21 at 4:42 p.m., an interview was conducted with OSM #3 (other staff member) #3 (the maintenance director). OSM #3 stated the maintenance staff inspects all resident wheelchairs including armrests every quarter and staff is supposed to report torn wheelchair armrests any other time via a work order in the computer system. OSM #3 stated he had previously ordered wheelchair armrests but had difficulty with getting the supply and the supply only recently came in. On 11/16/21 at 5:36 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the assistant administrator) and ASM #3 (the director of nursing) were made aware of the above concern. On 11/17/21 at 7:54 a.m., OSM #3 provided an invoice that documented wheelchair armrests were received at the facility on 10/15/21. OSM #3 also provided documentation to evidence Resident #21's wheelchair was inspected by the maintenance staff on 8/27/21 and stated he had not received any work orders from other staff regarding Resident #21's wheelchair armrests. On 11/17/21 at 9:42 a.m., ASM #1 and ASM #2 was made aware that the above findings remained a concern. The facility policy titled, Homelike Environment documented, Residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible. The facility policy titled, Wheelchair Cleaning and Maintenance Inspection documented, It is the policy of this facility to conduct regular cleaning and inspections of all wheelchairs and resident transportation equipment to ensure that they are cleaned and safe. Repairs and cleaning shall not be limited to the routine cleaning and inspection procedures. Any observation of an uncleaned device or device that needs repair should be cleaned and/or reported for repairs through the Tels work-order system (computerized work order system for the Maintenance department). No further information was presented prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for one of 44 residents in the survey sample, Resident # 106. The facility staff failed to ensure timely transcription of a an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician ordered the wound Vac on 11/12/21 and the order was not transcribed until 11/15/21. The findings include: Resident # 106's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/25/2021, coded Resident # 106 as scoring a 3 [three] on the brief interview for mental status (BIMS) of a score of 0 - 15, 3 [three] - being severely impaired of cognition for making daily decisions. The Wound Evaluation & Management Summary for Resident # 106 dated 11/12/2021 documented in part, Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] The Physician's Telephone Order for Resident # 106 dated 11/15/21 documented, Cleanse wound to R [right] hip with hibiscus wipe with dampened 4x4 [four by four] gauze, pack wound with black foam. Apply negative pressure therapy run continuous at 120 mmHg [millimeters of mercury]. Change dressing Tues [Tuesday], Friday and PRN [as needed]. The comprehensive care plan for Resident # 106 dated 07/02/2021 documented in part, Problem/Need: Infection/Wound to R [right] Hip. At risk for pain, odor, and infection due to right hip wound and comorbidities. Under Approaches it documented in part, 11/15/21 New wound care order Negative pressure therapy continuously @ [at] 120 mmHg [millimeter of mercury] per order. On 11/17/2021 at 8:09 a.m., an interview was conducted with LPN [licensed practical nurse] # 2, wound nurse. LPN #2 was asked when the wound vac treatment was started for Resident # 106. LPN # 2 stated that Resident # 106 had the negative wound vac on 11/12/2021 and had discontinued the PICO vac [3] on the 11/12/2021. After reviewing the physician's telephone order for Resident # 106's use of the wound vac as listed above, LPN # 2 was asked why the order was dated 11/15/2021 when they stated that the wound vac started on 11/12/2021. LPN # 2 stated, The order was not written until 11/15/2021. When asked who was responsible for transcribing the order, LPN # 2 stated, I was responsible for obtaining the order. When asked to describe the procedure for obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if the order for Resident # 106's wound vac was transcribed timely, LPN # 2 stated no. When asked about the date of the Approach on Resident # 106 comprehensive care plan, LPN # 2 stated that the care plan is updated when the order is written. On 11/15/2021 at approximately 12:00 p.m., during the entrance conference with ASM [administrative staff member] # 2, assistant administrator and ASM # 3, director of nursing, ASM # 3 stated that the facility's nursing staff follow Lippincott's standard of nursing. On 11/17/2021 at approximately 10:22 a.m. a request was made to ASM # 1, administrator for facility policies and the Lippincott standard of nursing for transcribing physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] # 2, assistant director of nursing, provided the survey team with requested policies. The facility was unable to provide the Lippincott standard of nursing for transcribing physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/17/2021 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, assistant administrator, ASM # 3, director of nursing, ASM # 4, administrator of sister facility and ASM # 5, nurse consultant, were made aware of the above findings. No further information was provided prior to exit. References: [1] Vacuum-assisted closure of a wound is a type of therapy to help wounds heal. It's also known as wound VAC. During the treatment, a device decreases air pressure on the wound. This can help the wound heal more quickly. The gases in the air around us put pressure on the surface of our bodies. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/vacuumassisted-closure-of-a-wound#:~:text=Vacuum%2Dassisted%20closure%20of%20a%20wound%20is%20a%20type%20of,the%20surface%20of%20our%20bodies. [2] A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm. [3] The PICO* patient/population, intervention, comparison and outcomes] Single Use Negative Pressure Wound Therapy System is indicated for acute and chronic wounds and closed surgical incisions with low to moderate levels of exudate. This single use system is canister-free with a wear time of 7 to 14 days. Approved for both hospital and home care settings. This information was obtained from the website: https://www.woundsource.com/product/pico-single-use-negative-pressure-wound-therapy-system.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for four of 51 residents in the survey sample, Residents #53, #104, #98 and #138. 1. On 3/5/19, Resident #53 was observed on separate occasions without her physician ordered continuous oxygen in place. The clinical record failed to evidence any documentation regarding staff reapplying the oxygen or the resident being noncompliant with wearing her oxygen and notification to the physician per the comprehensive care plan. 2. The facility staff failed to develop a comprehensive care plan to address Resident #104's diabetes and the care required. 3a. On 3/5/19 during separate observations Resident #98 was observed without prevalon boots in place per the physician orders [REDACTED]. 3b. The facility staff failed to develop a comprehensive care to address Resident # 98's sacral wound and the care required. 3c. The facility staff failed to implement Resident #98's comprehensive care plan for fall mats per physician order. On 3/5/19, separate observations revealed Resident #98 in bed with only one fall mat on the floor, on the left side of the resident's bed, instead of a fall mat to each side of the bed per the physician's orders [REDACTED]. 4. The facility staff failed to develop Resident #138's a comprehensive care plan to address the residents pain and the care required to address the residents pain. The findings include: 1. On 3/5/19, Resident #53 was observed on separate occasions without her physician ordered continuous oxygen in place. The clinical record failed to evidence any documentation regarding staff reapplying the oxygen or the resident being noncompliant with wearing her oxygen and notification to the physician per the comprehensive care plan. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. These substances are harmful to the kidney and often cause kidney damage (2)), [MEDICAL CONDITION] disc disease (disc disease is a common condition characterized by the breakdown (degeneration) of one or more of the discs that separate the bones of the spine (3)), and [MEDICAL CONDITION] (general term for chronic, nonreversible lung disease that is usually a combination of [MEDICAL CONDITION] and chronic [MEDICAL CONDITION] (4)). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/21/18, coded the resident as scoring a 8 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make cognitive daily decisions. The resident was coded as completely dependent upon one or more staff members for all of her activities of daily living. In Section O - Special Treatments, Procedures and Programs the resident was coded as using oxygen while a resident in the facility. Resident #53 was observed on 3/5/19 at 9:05 a.m., the resident was in her bed, drinking some water. The oxygen tubing was not on the resident. The oxygen tubing was observed hanging over the end of the tubing closest to the concentrator. The tubing was not touching the ground. The oxygen concentrator was running. A second observation was made of Resident #53 on 3/5/19 at 12:33 p.m. The resident was in bed asleep. The oxygen concentrator was running and the tubing remained hanging off the tubing closet to the concentrator, and was not on the resident. The third observation of Resident #53 on 3/5/19 at 3:42 p.m. revealed the resident receiving her oxygen via a nasal cannula (a tubing with two prongs that insert into the nose) connected do an oxygen concentrator that was running. The physician order [REDACTED]. The comprehensive care plan reviewed on 12/21/18, documented in part, Problem: Per staff Resident is non-compliant with O2 at times, takes O2 off. The Approaches documented in part, Encourage O2 use as ordered. Educate resident about being non-compliant with O2 use. Document and report to MD (medical doctor) and RP (responsible party) as needed. Replace O2 when noticed off. Review of the nurse's notes for 3/5/19 failed to evidence documentation of the staff reapplying the resident's oxygen or, that the resident was noncompliant with wearing her oxygen and notification to the physician of non-compliance. An interview was conducted with RN (registered nurse) #3, the unit manager, on 3/6/19 at 3:15 p.m. RN #1 was asked if a resident has an order for [REDACTED].#3 stated it would not be following the care plan. An interview was conducted with LPN (licensed practical nurse) #9 on 3//6/19 at 3:33 p.m. When asked if the resident did not have her oxygen on per the physician order, and the care plan documents to administer oxygen per the physician order, were the staff following the care plan, LPN #9 stated, No. The facility policy, Care Plans, Comprehensive Person-Centered documented in part, 1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 286. (2) This information was obtained from the following website: https://medlineplus.gov/ency/article/ 3.htm (3) This information was obtained from the following website: https://ghr.nlm.nih.gov/condition/intervertebral-disc-disease. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. 2. The facility staff failed to develop a comprehensive care plan to address Resident #104's diabetes and the care required. Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 2/2/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as requiring from limited to total assistance for his activities of daily living. In Section I - Health Conditions, the resident was coded as having diabetes. The comprehensive care plan dated 1/13/19 was reviewed. The care plan failed to address the resident's diabetes and care required including that he receives insulin. The physician orders [REDACTED]. An interview was conducted with LPN (licensed practical nurse) #1 on 3/6/19 at 11:55 a.m. When asked if a resident has diabetes, should that be addressed on their care plan, LPN #1 stated, I believe so. LPN #1 was asked to review Resident #104's care plan. After the review, LPN #1 was asked if the resident's [DIAGNOSES REDACTED].#1 stated, I don't see it. An interview was conducted with RN (registered nurse) #3, the unit manager, on 3/6/19 at 11:57 a.m. When asked if a resident with diabetes should have a care plan to address the diabetes, RN #3 stated, Yes, it should be. RN #3 was asked to review Resident #104's care plan. After the review, RN #3 stated, It's not there. RN #3 looked in the clinical record and found the diabetes addressed on the baseline care plan but she said it didn't get carried over to the comprehensive care plan. When asked if it should have been carried over to the comprehensive care plan, RN #3 stated, Yes. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 266. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 7.html 3a. On 3/5/19 during separate observations Resident #98 was observed without prevalon boots in place per the physician orders [REDACTED]. Resident #98 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #98's Minimum Data Set (significant change in status) with an Assessment Reference Date of 01/18/2019 coded Resident #98 with severe cognitive impairment. In addition, the Minimum Data Set coded Resident #98 as requiring total assistance of one staff member with activities of daily living and total dependence for eating (tube feeding). On 03/05/2019 at approximately at 8:40 a.m., Resident #98 was observed lying in bed, on her right side, under a light green colored blanket with feet exposed. Resident #98 had on gray socks and both feet were propped up on a pillow. On 03/05/2019 at approximately 1:59 p.m., Resident #98 was observed lying in bed, on her back, under a light green colored blanket with feet exposed. Resident #98 had on gray socks and both feet were observed propped up on a pillow. On 03/05/2019, Resident #98's care plan was reviewed. Resident #98's care plan and physician order [REDACTED]. Resident #98 did not have prevalon boots on when observed at approximately 8:40 a.m. and at 1:59 p.m. On 03/05/2019 at approximately 3:51 p.m., Resident 98 was observed lying in bed, on her back, under a light green colored blanket with feet covered. Resident #98's feet were covered. LPN (Licensed Practical Nurse) #4 was asked to remove Resident #98's blanket to reveal both feet. Resident #98 had on gray socks and both feet were observed propped up on a pillow. Resident # 98 was not wearing prevalon boots. LPN #4 asked Resident #98, Where are your prevalon boots? Resident # 98 did not respond. LPN #4 then placed prevalon boots on Resident #98's feet, which were located behind the television. An interview was conducted on 03/06/2019 at approximately 10:23 a.m. with RN #1 (Registered Nurse) (Unit Manager). RN #1 was asked what the purpose of the resident's care plan is. RN #1 stated that the care plan is what's used to let nursing staff know what the resident needs are. RN #1 was asked who is responsible for developing the care plan. RN #1 stated that the MDS (Minimal Data Set) Coordinator is responsible for developing the care plan. RN #1 was asked who is responsible for implementing the care plan. RN #1 stated that the MDS Coordinator is responsible for implementing the care plan. RN #1 was asked staff ensure care plan interventions are in place and implemented. RN #1 stated that rounds are made to ensure that care planned interventions are in place. RN #1 was made aware of Resident #98 not wearing prevalon boots as ordered and care planned. RN #1 stated that he made sure the resident was wearing her prevalon boots after looking at her orders. An interview was conducted on 03/06/2019 at approximately 2:42 p.m. with LPN #2 (Licensed Practical Nurse) (MDS Coordinator). LPN #2 was asked who is responsible for developing and updating resident's care plan. LPN #2 stated, MDS is responsible for developing and updating the care plans. LPN #2 was asked the purpose of the care plan. LPN #2 stated that the purpose of the care plan is to keep nursing staff informed of resident's plan of care. On 03/06/2019 at approximately 12:30 p.m., ASM (Administrative Staff Member) #1 (Administrator), ASM #3 (Regional Nurse Consultant), and ASM #4 (Regional Vice President of Operations) were made aware of findings. 3b. The facility staff failed to develop a comprehensive care to address Resident # 98's sacral wound and the care required. Resident #98's Minimum Data Set (MDS) with an Assessment Reference Date of 01/18/2019 coded Resident #98 in Section M Skin Conditions M0100 A., Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Section M Skin Conditions M0150 Risk of Pressure Ulcers/Injuries coded, Resident is at risk of developing pressure ulcers/injuries. Section M Skin Conditions M0300 F. coded Resident #98 as having 1 unstageable pressure ulcer/injury (1) that was present upon admission. On 03/06/2019, Resident #98's clinical record was reviewed. A physician order [REDACTED]. Resident #98 did not have a comprehensive care plan addressing her sacral wound and the care required. An interview was conducted on 03/06/2019 at approximately 2:42 p.m. with LPN #2 (Licensed Practical Nurse) (MDS Coordinator). LPN #2 (MDS Coordinator) was asked who is responsible for developing and updating resident's care plan. LPN #2 stated, MDS is responsible for developing and updating the care plans. LPN #2 (MDS Coordinator) was asked what is the purpose of the care plan. LPN #2 (MDS Coordinator) stated that the purpose of the care plan is to keep nursing staff informed of resident's plan of care. LPN #2 (MDS Coordinator) was made aware of Resident #98 not having a wound care plan to address the resident's sacral wound and the care required. LPN #2 (MDS Coordinator) reviewed Resident #98's care plan and validated that there was not a wound care plan in the comprehensive care plan and that Resident #98 did have a sacral wound. On 03/06/2019 at approximately 12:30 p.m., ASM (Administrative Staff Member) #1 (Administrator), ASM #3 (Regional Nurse Consultant), and ASM #4 (Regional Vice President of Operations) were made aware of findings. References: (1) Pressure ulcers are also called bedsores, or pressure sores. They can form when your skin and soft tissue press against a harder surface, such as a chair or bed, for a prolonged time. This reduces blood supply to that area. Lack of blood supply can cause the skin tissue in this area to become damaged or die. This information was obtained from the website: https://medlineplus.gov/ency.patientinstructions/ 7.htm 3c. The facility staff failed to implement Resident #98's comprehensive care plan for fall mats per physician order. On 3/5/19, separate observations revealed Resident #98 in bed with only one fall mat on the floor, on the left side of the resident's bed, instead of a fall mat to each side of the bed per the physician's orders [REDACTED]. On 03/05/2019 at approximately at 8:40 a.m., Resident #98 was observed lying in bed, on her right side, under a light green colored blanket with feet exposed. One fall mat was on the left side Resident #98's bed on the floor. On 03/05/2019 at approximately 1:59 p.m., Resident #98 was observed lying in bed, on her back, under a light green colored blanket with feet exposed. One fall mat was on the left side Resident #98's bed on the floor. On 03/05/2019, Resident #98's clinical record was reviewed. Resident #98's comprehensive care plan documented, Fall mat times two to bedside for safety dated 03/22/2018. Resident # 98 had a physician order [REDACTED]. An interview was conducted on 03/06/2019 at approximately 10:23 a.m. with RN #1 (Registered Nurse) (Unit Manager). RN #1 was asked what the purpose of the resident's care plan is. RN #1 stated that the care plan is what's used to let nursing staff know what the resident needs are. RN #1 was asked who is responsible for developing the care plan. RN #1 stated that the MDS (Minimal Data Set) Coordinator is responsible for developing the care plan. RN #1 was asked who is responsible for implementing the care plan. RN #1 stated that the MDS Coordinator is responsible for implementing the care plan. RN #1 was asked how staff ensure care plan interventions are implemented and in place. RN #1 stated that rounds are made to ensure that care plan interventions are in place. RN #1 was made aware of Resident #98 not having a fall mat on both sides of the bed. RN #1 stated that he corrected the issue after reviewing the orders and care plan. On 03/06/2019 at approximately 12:30 p.m., ASM (Administrative Staff Member) #1 (Administrator), ASM #3 (Regional Nurse Consultant), and ASM #4 (Regional Vice President of Operations) were made aware of findings. 4. The facility staff failed to develop Resident #138's a comprehensive care plan to address the residents pain and the care required to address the residents pain. Resident #138 was admitted to the facility on [DATE]. Resident #138's [DIAGNOSES REDACTED]. Resident #138's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 2/15/19, coded the resident's cognition as severely impaired. Section J coded Resident #138 as having received PRN (as needed) pain medication and non-medication intervention during the last five days. Section J further coded Resident #138 reported having frequent pain during the last five days. Section V documented pain as a triggered care area and documented pain as being addressed in the care plan. Review of Resident #138's clinical record revealed a physician's orders [REDACTED]. Review of Resident #138's (MONTH) 2019 MAR (medication administration record) revealed the resident was administered PRN Tylenol on 2/4/19, 2/5/19, 2/6/19, 2/10/19, 2/11/19, 2/12/19, 2/14/19, 2/15/19 and 2/18/19. Review of Resident #138's comprehensive care plan dated 2/15/19 failed to reveal documentation regarding pain. On 3/6/19 at 11:32 a.m., an interview was conducted with LPN (licensed practical nurse) #5 (the nurse who administered PRN Tylenol to Resident #138 on all of the above dates except 2/10/19). LPN #5 confirmed she administered Tylenol to Resident #138 for pain. When asked if a resident who is receiving pain medication should have a pain care plan, LPN #5 stated, Yes. On 3/6/19 at 4:13 p.m., an interview was conducted with RN (registered nurse) #2 (the nurse responsible for developing care plans). RN #2 was made aware of the above concern. RN #2 confirmed Resident #2 should have had a pain care plan and stated she created one on this date. On 3/6/19 at 4:50 p.m., ASM (administrative staff member) #1 (the administrator), ASM #3 (the regional nurse consultant) and ASM #4 (the regional vice president of operations) was made aware of the above concern. The facility policy titled, Care Plans, Comprehensive Person-Centered documented, Policy Statement: A comprehensive, person-centered car plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . The CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual documented: SECTION V: CARE AREA ASSESSMENT (CAA) SUMMARY Intent: The MDS does not constitute a comprehensive assessment. Rather, it is a preliminary assessment to identify potential resident problems, strengths, and preferences. Care Areas are triggered by MDS item responses that indicate the need for additional assessment based on problem identification, known as triggered care areas, which form a critical link between the MDS and decisions about care planning. There are 20 CAAs in Version 3.0 of the RAI, which includes the addition of Pain and Return to the Community Referral. These CAAs cover the majority of care areas known to be problematic for nursing home residents. The Care Area Assessment (CAA) process provides guidance on how to focus on key issues identified during a comprehensive MDS assessment and directs facility staff and health professionals to evaluate triggered care areas. The interdisciplinary team (IDT) then identifies relevant assessment information regarding the resident's status. After obtaining input from the resident, the resident's family, significant other, guardian, or legally authorized representative, the IDT decides whether or not to develop a care plan for triggered care areas. No further information was presented prior to exit. (1) Tylenol is used to relieve pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 4.html

Based on staff interview, clinical record review and facility document review, the facility staff failed to evidence all required documentation was provided to the receiving facility at the time of a facility initiated transfer, for seven of 51 sampled residents; ( Residents #95, #141, #137, #45, #153, #92, and #38). 1. The facility staff failed to evidence that the comprehensive care plan goals for Resident #95 were provided to the receiving facility when the resident was transferred to the hospital on [DATE]. 2. The facility staff failed to evidence that the comprehensive care plan goals for Resident #141 were provided to the receiving facility when the resident was transferred to the hospital on [DATE], 12/23/18, and 1/23/19. 3. The facility staff failed to evidence that comprehensive care plan goals for Resident # 137 were sent with the resident to the hospital for the transfer on 02/19/19. 4. The facility staff failed to provide the receiving facility with the Resident #45's comprehensive care plan goals for a facility initiated hospital transfer that occurred on 11/25/18. 5. The facility staff failed to evidence that the comprehensive care plan goals for Resident #153 were provided to the receiving facility when the resident was transferred to the hospital on [DATE]. 6. The facility staff failed to provide evidence that all required information (including physician contact information, resident representative contact information, special instructions for ongoing care, advance directives and comprehensive care plan goals) was provided to the hospital staff when Resident #92 was transferred to the hospital on [DATE]. 7. The facility staff failed to evidence that the comprehensive care plan goals were provided to the receiving facility when Resident #38 was transferred to the hospital on [DATE]. The findings include: 1. The facility staff failed to evidence that the comprehensive care plan goals for Resident #95 were provided to the receiving facility when the resident was transferred to the hospital on [DATE]. Resident #95 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a significant change assessment with an ARD (Assessment Reference Date) of 1/25/19. The resident was coded as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living. A review of the clinical record revealed a nurse's note dated 1/11/19 at 11:24 a.m. that documented, Resident reported to have discoloration to left lower extremity. Resident assessed by supervisor and pedal pulses unable to be found. Provider called and order obtained to send patient to ER (emergency room ) for evaluation. RP (responsible party) called and messages left for two contacts to call back for updates. (Name of county) called for emergency transport. Resident unable to understand reason for transport and is unable to sign bed hold form. (Name of hospital) ER called and given report to (name of ER staff). (Name of county ambulance) departing with patient at 10:33 am to (name of hospital) ER. Further review of the clinical record failed to reveal what documentation was provided to the hospital. On 3/06/19 at 2:04p.m., an interview was conducted with LPN #8 (Licensed Practical Nurse), the unit manager for Resident #95. LPN #8 stated that when the resident goes to the hospital, the facility sends 2 copies of the facesheet, one for transport and one for hospital, the resident's History and Physical, immunization record, last recertification, last progress note, labs, Medication Administration Record, [REDACTED]. When asked about the comprehensive care plan goals, LPN #8 stated, We do not send the care plan. When asked what is included on the transfer form. LPN #8 stated, The resident's name, date time, where they are being sent to, the address, phone number, allergies [REDACTED]. We use a checklist; it is in a packet of forms to be filled out. LPN #8 provided a copy of this packet and checklist. A review of the When Sending A Resident To The Hospital checklist failed to include that comprehensive care plan goals must be provided. The facility policy, Transfer or Discharge, Emergency was reviewed. The policy did not include requirements of what documentation, including comprehensive care plan goals, must be provided to the receiving facility. On 3/06/19 at 6:36 p.m., ASM #1 (Administrative Staff Member - the Administrator) was made aware of the findings. No further information was provided by the end of the survey. 2. The facility staff failed to evidence that the comprehensive care plan goals for Resident #141 were provided to the receiving facility when the resident was transferred to the hospital on [DATE], 12/23/18, and 1/23/19. Resident #141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a 30 day readmission assessment with an ARD (Assessment Reference Date) of 3/6/19. The resident was coded as being mildly impaired in ability to make daily life decisions. A review of the clinical record revealed the following: Regarding the 1/23/19 hospitalization : A nurse's note dated 1/23/19 documented, Nurse was at the nursing station when the gentleman that transports residents across the street for church service at 7 pm states that he went in resident's room and resident was unresponsive and drooling allover {sic} himself charge nurse immediately went to evaluate resident. Resident noted to be slouched over to the right side of his wheelchair and drool dripping from mouth Nurse called out resident's name a couple of times with no response so then nurse performed a forceful sternal rub again no stimulation verbally or physically from resident Supervisor contacted MD (medical doctor) to make aware of resident's condition. Order obtained to send to ER (emergency room ) for further evaluation Charge nurse stayed with resident upon nursing assessment right sided face droop present, both pupils fixed, resident unable to speak all these symptoms are new onset. Symptoms appear to be stroke like EMS (emergency medical service) arrived to transport resident via stretcher to (name of hospital) for further evaluation Regarding 12/23/18 hospitalization : A nurse's note dated 12/23/18 documented, At 5:30 am CNA (certified nursing assistant) notified this writer of rectal bleeding; upon assessment: moderate amount dark red blood, mixed with clots oozing from rectum; blood continued to ooze post area being cleansed order given to transfer resident to acute care Regarding 12/13/18 hospitalization : A nurse's note dated 12/13/18 documented, Resident being transported to (hospital) via ambulance for eval (evaluation) of possible ileus and obstruction. Resident started with cold symptoms on 12/8 (2018) which led to a chest x-ray to rule out pneumonia the chest x-ray suggested possible colonic ileus, MD (medical doctor) made aware. MD ordered KUB (Kidney, Ureter, Bladder test) to investigate since resident had two bowel movements on the 11th. KUB performed on the 12th, called for results on the 13th, verbal results given as positive for colonic ileus, possible obstruction and abnormal gas pattern. MD notified and order obtained to send to hospital for eval (evaluation) Further review of the clinical record failed to reveal what documentation was provided to the hospital for each of the above hospitalization s. On 3/06/19 at 2:22 p.m., in an interview with RN #1 (Registered Nurse, the unit manager for Resident #141), when asked what paperwork is sent to the hospital, he stated, We send the transfer packet, face sheet, immunizations, we go right down the checklist. When asked if the comprehensive care plan goals are sent, RN #1 stated, We do not send the care plan goals. A review of the When Sending A Resident To The Hospital checklist failed to include that comprehensive care plan goals must be provided. The facility policy, Transfer or Discharge, Emergency was reviewed. The policy did not include requirements of what documentation, including comprehensive care plan goals, must be provided to the receiving facility. On 3/06/19 at 6:36 p.m., ASM #1 (Administrative Staff Member - the Administrator) was made aware of the findings. No further information was provided by the end of the survey. 3. The facility staff failed to evidence that comprehensive care plan goals for Resident # 137 were sent with the resident to the hospital for the transfer on 02/19/19. Resident # 137 was admitted to the facility on [DATE] with a readmission of 02/21/19 with [DIAGNOSES REDACTED]. Resident # 137's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/14/19, coded Resident # 137 as scoring a 3 (three) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 3(three) - being severely impaired of cognition for making daily decisions. The nurse's Progress Notes, dated 02/19/2019 for Resident # 137 documented, On last evening rounds this shift (2/18/19) resident was noted with (increased) audible congestion and had rbronchi (right [MEDICATION NAME]) (lung) in upper lobes and rattles in all lung fields. VS (vital signs) were 101.8 (temperature), 189/96 (189 over 96 blood pressure). Pulse went to 127. PRN (as needed) Tylenol [MEDICATION NAME] 20.3 cc (cubic centimeters) per peg (tube feeding) given for (increased) temp (temperature) with cool water via (by) peg. Pox (Pulse oximetry) 88-91% on O2 (oxygen) 2 (two) L/nc (liters by nasal cannula), O2 (increased) to 4l?nc. NP (nurse practitioner) (Name of Nurse Practitioner) notifies and (sic) ordered send resident out to (sic) hospital ER (emergency room ) for evaluation. RP (responsible party) (Name of Responsible Party) made aware and stated she would decline bed hold offer. Squad notified and in to p/u (pick up) resident at 0015 (12:15 a.m.), (sic) nonbreather mask applied, pox (increased) to 95% with O2. (Name of Transport) squad left facility with resident for (Name of Hospital) via stretcher at 0030 (12:30 a.m.) RP was called back and notified that resident was sent to (Name of Hospital) ER. Stated to let her know if resident will be admitted to hospital. Review of the clinical record and the facility's Resident Transfer Form dated 02/19/19 for Resident # 137 failed evidence documentation that the care plan goals were sent to (Name of Hospital) upon the transfer of Resident # 137. On 3/06/19 at 2:04p.m., an interview was conducted with LPN #8 (Licensed Practical Nurse), the unit manager for Resident #95. LPN #8 stated that when the resident goes to the hospital, the facility sends 2 copies of the facesheet, one for transport and one for hospital, the resident's History and Physical, immunization record, last recertification, last progress note, labs, Medication Administration Record, [REDACTED]. When asked about the comprehensive care plan goals, LPN #8 stated, We do not send the care plan. The facility policy, Transfer or Discharge, Emergency was reviewed. The policy did not include requirements of what documentation, including comprehensive care plan goals, must be provided to the receiving facility. On 03/06/19 at approximately 3:30 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) An illness in which the body has a severe, [MEDICAL CONDITION] response to bacteria or other germs. The symptoms [MEDICAL CONDITION] are not caused by the germs themselves. Instead, chemicals the body releases cause the response. This information was obtained from the website: https://medlineplus.gov/ency/article/ 6.htm. (2) A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. This information was obtained from the website: https://medlineplus.gov/ency/article/ 7.htm. (3) Also called: [MEDICAL CONDITION], Palsy, [MEDICAL CONDITIONS]. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. 4. The facility staff failed to provide the receiving facility with the Resident #45's comprehensive care plan goals for a facility initiated hospital transfer that occurred on 11/25/18. Resident # 45 was admitted to the facility on [DATE] and a re-admission on 11/30/18 with [DIAGNOSES REDACTED]. Resident # 45's most recent MDS (minimum data set), a 30-day assessment with an ARD (assessment reference date) of 12/19/18, coded Resident # 45 as scoring a 9 (nine) on the brief interview for mental status (BIMS) of a score of 0 - 15, 9 (nine) - being moderately impaired of cognition for making daily decisions. The nurse's Progress Notes, dated 11/25/2018 for Resident # 45 at 11:53 p.m. documented, At end of evening shift (2200) (10:00 p.m.) res (resident) was again offered water and juice, refused both. Total intake for shift was approx. (approximately) 120 cc (cubic centimeters), with much effort. Res cont (continues) to say I don't want any water or juice. Foley (catheter) 0 (zero) - (to) 100 cc cloudy amber urine, no stool in [MEDICAL CONDITION] bag this shift. Res denies any pain when asked. At 2230 (10:30 p.m.) NP (nurse practitioner) (Name of Nurse Practitioner) notified and gave verbal order to send resident out to hospital ER (emergency room ) for evaluation to rule out possible bowel obstruction. Night supervisor was made aware. Attempts made to contact RP (responsible party) on all 3 numbers. (Name of Transport) squad in, stated both (Name of two Hospitals) were on diversion. Call placed by EMT (emergency medical technician) to (Name of Hospital) ER nurse, who stated they had no available beds but would accept resident with possible transfer to another hospital. Squad left with res en route to (Name of Hospital) at 2345 (11:45 p.m.). Review of the facility's Resident Transfer Form dated 11/25/18 for Resident # 45 failed evidence documentation that the care plan goals were sent to (Name of Hospital) upon the transfer of Resident # 45. On 3/06/19 at 2:04p.m., an interview was conducted with LPN #8 (Licensed Practical Nurse), the unit manager for Resident #95. LPN #8 stated that when the resident goes to the hospital, the facility sends 2 copies of the facesheet, one for transport and one for hospital, the resident's History and Physical, immunization record, last recertification, last progress note, labs, Medication Administration Record, [REDACTED]. When asked about the comprehensive care plan goals, LPN #8 stated, We do not send the care plan. The facility policy, Transfer or Discharge, Emergency was reviewed. The policy did not include requirements of what documentation, including comprehensive care plan goals, must be provided to the receiving facility. On 03/06/19 at approximately 3:30 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) An infection in the urinary tract. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm. (2) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (3) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm. (4) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. 5. The facility staff failed to evidence that the comprehensive care plan goals for Resident #153 were provided to the receiving facility when the resident was transferred to the hospital on [DATE]. Resident #153 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #153's Minimum Data Set (MDS) was a significant change in status assessment with an Assessment Reference Date (ARD) of 1/15/19, and coded Resident #153 as severely impaired for cognitive skills for daily decision-making. A review of the clinical record revealed a nurse's note dated 2/15/19 at 12:45 p.m., that documented, 1:1 monitoring has continued since beginning of shift. at 1140-(Name of Doctor) in and spoke with md (medical doctor) re (regarding): transferring resident to more appropriate setting for safety of resident and other, and order written to go to (Name of hospital) ER (emergency room ) for psych (psychiatric) eval (evaluation) for possible admission re: behaviors. This writer left msg (message) for rp (Responsible Party) to return call to facility. resident was oriented that he was being sent to (Name of hospital) ER in (Name of town, state) by stretcher for eval (evaluation) and possible admit to hospital to help with his previous behaviors, resident smiled and said 'okay.' at 1150 spoke with (Name of transport staff) at (Name of transport ambulance) to transport resident to (Name of hospital) er. at 1225 2 attendants with (Name of transport ambulance) in facility and enroute via stretcher to (Name of hospital) ER at 1235. at 1242 report was given to (name of ER staff) rn (Registered Nurse) at (Name of hospital) er. Further review of the clinical record failed to reveal what documentation was provided to the hospital. On 3/06/19 at 2:04p.m., an interview was conducted with LPN #8 (Licensed Practical Nurse), the unit manager for Resident #95. LPN #8 stated that when the resident goes to the hospital, the facility sends 2 copies of the facesheet, one for transport and one for hospital, the resident's History and Physical, immunization record, last recertification, last progress note, labs, Medication Administration Record, [REDACTED]. When asked about the comprehensive care plan goals, LPN #8 stated, We do not send the care plan. The facility policy, Transfer or Discharge, Emergency was reviewed. The policy did not include requirements of what documentation, including comprehensive care plan goals, must be provided to the receiving facility. On 3/7/19 at approximately 6:26 p.m., AMS #1 (Administrative Staff Member - the Administrator) was made aware of the findings. No further information was provided by the end of the survey. 6. The facility staff failed to provide evidence that all required information (including physician contact information, resident representative contact information, special instructions for ongoing care, advance directives and comprehensive care plan goals) was provided to the hospital staff when Resident #92 was transferred to the hospital on [DATE]. Resident #92 was admitted to the facility on [DATE]. Resident #92's [DIAGNOSES REDACTED]. Resident #92's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/18/19, coded the resident as being cognitively intact. Review of Resident #92's clinical record revealed the resident presented with a fever and nausea, and was transferred to the hospital on [DATE]. Further review of Resident #92's clinical record (including nurses' notes) failed to reveal evidence that the facility staff provided the required information to hospital staff when the resident was transferred. On 3/6/19 at 10:28 a.m., an interview was conducted with LPN (licensed practical nurse) #4 and RN (registered nurse) #1. LPN #4 and RN #1 were asked to describe the information that is provided to hospital staff when a resident is transferred to the hospital. LPN #4 stated she provides physician orders, recent labs, recent x-rays, a history and physical, immunization record and face sheet. LPN #4 confirmed she does not provide comprehensive care plan goals. LPN #4 stated the nurses have a transfer form with instructions and a check off list. RN #1 stated a copy containing all the information on the check off list is sent to the hospital and a copy is placed in the resident's clinical record. RN #1 stated the process for sending information to the hospital had been revised multiple times over the last year and the process was recently revised so he was not sure if this process was in place when Resident #92 was transferred to the hospital. On 3/6/19 at 3:41 p.m., RN #1 confirmed he could not provide evidence that the required information was provided to hospital staff when Resident #92 was transferred to the hospital on [DATE]. On 3/6/19 at 4:50 p.m., ASM (administrative staff member) #1 (the administrator), ASM #3 (the regional nurse consultant) and ASM #4 (the regional vice president of operations) was made aware of the above concern. No further information was presented prior to exit. 7. The facility staff failed to evidence that the comprehensive care plan goals were provided to the receiving facility when Resident #38 was transferred to the hospital on [DATE]. Resident #38 was admitted to the facility on [DATE] with a recent readmission on 11/21/18, with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 2/27/19, coded the resident as having both short and long term memory difficulties. The nurse's note dated 11/10/18 at 2:02 a.m. documented in part, Late entry for evening shift - Res (resident) rested well in bed, IV (intravenous) of NS (normal saline) infusing in rt (right) forearm .Noted with increased coughing episode at supper, only ate a few bites. RP (responsible party) in to visit. Attendants in to pick up resident for (Name of Hospital) for evaluation of lethargy and decreased intake. Review of the clinical record failed to reveal any documentation evidencing what information was provided to the receiving hospital at the time of the residents transfer on 11/10/19. On 3/06/19 at 2:04p.m., an interview was conducted with LPN #8 (Licensed Practical Nurse), the unit manager for Resident #95. LPN #8 stated that when the resident goes to the hospital, the facility sends 2 copies of the facesheet, one for transport and one for hospital, the resident's History and Physical, immunization record, last recertification, last progress note, labs, Medication Administration Record, [REDACTED]. When asked about the comprehensive care plan goals, LPN #8 stated, We do not send the care plan. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. No further information was obtained prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 527.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to provide a dignified, homelike dining experience in one of 3 facility dining rooms, the Cottage dining room and failed to promote resident dignity during a meal for one of 51 sampled residents, Resident # 86's. 1. In the Cottage dining room (the memory care unit), the 27 residents present for the lunch meal on 3/5/19, were served their meals cafeteria style, on trays. 2. The facility staff failed to respect Resident # 86's dignity by standing next to her while providing assistance with feeding during the breakfast meal on 3/6/19. The findings include: 1. On 3/05/19 at 1:08 p.m., observation of the Cottage dining room was conducted during the lunch meal. There were 27 residents in the dining room when the tray cart arrived at this time. The dining room staff served all 27 residents their meal on the trays, cafeteria style. No attempt was made to remove the residents' meals from the trays and place them on the table for a homelike dining experience. On 3/05/19 at 3:44 p.m., an interview was conducted with CNA #4 (Certified Nursing Assistant), one of the staff members serving the residents. When asked if the residents should be served their meals that way, CNA #4 stated, That's how I've been taught for 9 years. When asked if that is a cafeteria or homelike dining experience, CNA #4 she stated, Cafeteria. When asked what kind of dining experience are they supposed to have, CNA #4 stated, A home setting. When asked is it homelike if they are being served on trays, CNA #4 stated, Probably not, I don't think so. CNA #4 then stated, It isn't that way on the other units but on this unit that is how they do it. I don't know if it is because it is a different unit. When asked should it be different, CNA #4 stated, No, it should be the same. A review of the facility policy Quality of Life - Dignity documented, 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . The policy did not specifically identify what style of dining should be utilized for a dignified, homelike dining experience. On 3/05/19 at 5:07 p.m., ASM #1 (Administrative Staff Member - The Administrator) was made aware of the findings. No further information was provided by the end of the survey. 2. The facility staff failed to respect Resident # 86's dignity by standing next to her while providing assistance with feeding. Resident # 86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 86's most recent comprehensive MDS (minimum dada set) a quarterly assessment with an ARD (assessment reference date) of 01/12/19 coded the resident as scoring a 6 (six) on the brief interview for mental status (BIMS) of a score of 0 (zero) - 15, 6 (six) being severely impaired of cognition for daily decision making. Resident # 86 was coded as totally dependent of one staff member for activities of daily living. Resident # 86 was coded as totally dependent of one staff member for eating. Under Section K Swallowing/Nutritional Status Resident # 86 was coded as having a mechanically altered diet. On 03/06/19, an observation was conducted of Resident # 86 from 8:33 a.m. to 8:44 a.m. Resident # 86 was observed in her bed with the head of the elevated and the bed lowered close to the floor. CNA (certified nursing assistant) # 3 was observed bringing in Resident # 86's breakfast on a tray. CNA # 3 then placed the breakfast tray on Resident # 89's over-the-bed table, opened all the containers moved the table over the bed in front of Resident # 86 and provided verbal prompts to encourage Resident # 86 to try to feed herself. While standing next to Resident # 86's bed, CNA # 3 provided total assistance to Resident # 86 by feeding her the breakfast meal. On 03/06/19 at 8:46 a.m., an interview was conducted with CNA # 3. When asked if Resident # 86 was able to feed herself, CNA # 3 stated, 'Yes but she doesn't eat much so I provide assistance to try and get her to eat more. When asked what her position should be when assisting a resident with eating, CNA # 3 stated, I should be sitting down. When asked if she was sitting down while feeding Resident # 86 her breakfast, CNA # 3 stated, No I didn't think about it. I just wanted to get it done. When asked why it is important to sit next to or in front of a resident when feeding them, CNA # 3 stated, So you can be eye level with them. The comprehensive care plan for Resident # 86 dated 01/12/9 documented, Problem/Need. NUTRITIONAL RISK DUE TO MULTIPLE [DIAGNOSES REDACTED]. Swallowing issues. Poor intake. Under Approaches it documented, Provide diet as ordered. Monitor weight as ordered. Monitor and provide food preferences. The facility's Resident Rights documented, 10. Is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs. The facility's policy Quality of Life - Dignity documented, policy Statement. Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Under Policy Interpretation and Implementation it documented, 2. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 12. Staff shall treat cognitively impaired residents with dignity and sensitivity. The facility's policy Assistance with Meals documented, 3. Residents Requiring Full Assistance: b. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: (1) Not standing over residents while assisting them with meals . On 03/26/19 at approximately 3:30 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) A mental disorder that makes it hard to tell the difference between what is real and not real. This information was obtained from the website: https://medlineplus.gov/ency/article/ 8.htm. (2) Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. (3) A brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. This information was obtained from the website: https://www.nimh.nih.gov/health/topics/[MEDICAL CONDITION]-disorder/index.shtml. (4) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence written notification of the hospital transfer was provided to the resident and or responsible party for five of 51 residents in the survey sample; Residents #141, #45, #153, #92, #38. 1. The facility staff failed to evidence that Resident #141's responsible party was provided with written notification of the hospital transfer when the resident was transferred to the hospital on [DATE]. 2. The facility staff failed to provide Resident # 45 or the resident's representative written notification when the resident was transferred to the hospital on [DATE]. 3. The facility staff failed to evidence that Resident #153's responsible party was provided with written notification of the hospital transfer when the resident was transferred to the hospital on [DATE]. 4. Resident #92 was transferred to the hospital on [DATE]. The facility staff failed to provide written notification of the transfer to Resident #92 and/or the resident's representative. 5. The facility staff failed to provide written notification to the resident and/or responsible party, of a facility initiated transfer for Resident #38 on 11/9/18. The findings include: 1. The facility staff failed to evidence that Resident #141's responsible party was provided with written notification of the hospital transfer when the resident was transferred to the hospital on [DATE]. Resident #95 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a significant change assessment with an ARD (Assessment Reference Date) of 1/25/19. The resident was coded as severely cognitively impaired in ability to make daily life decisions. A nurse's note dated 12/23/18 documented, At 5:30 am CNA notified this writer of rectal bleeding; upon assessment: moderate amount dark red blood, mixed with clots oozing from rectum; blood continued to ooze post area being cleansed order given to transfer resident to acute care Further review of the clinical record failed to reveal any evidence that the responsible party was notified in writing of the hospital transfer. On 3/06/19 at 2:45 p.m., in an interview with OSM #2 (Other Staff Member, Director of Social Services) she stated that she sends the Discharge/Transfer form to the responsible party, but that this only started in (MONTH) 2019. A review of the Discharge/Transfer Form which was documented as being created (MONTH) 2019, documented, I understand that I am being discharged /transferred from (facility). I understand the reason for discharge/transfer is: (two long lines provided for writing in the reason for the transfer) Responsible Party Signature: (long line provided for signature); Date: (line provided for date); Copy Given (a box to check for this option provided); Copy Mailed on: (a line provided for the writing in of the date the notice was mailed to the responsible party) This form was not utilized during the time of the above hospital transfer. A review of the facility policy, Transfer or Discharge, Emergency documented, 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures e. Notify the representative (sponsor) or other family member . The policy did not specify that notification must occur in writing. On 3/06/19 at 6:36 p.m., ASM #1 (Administrative Staff Member - the Administrator) was made aware of the findings. No further information was provided by the end of the survey. 2. The facility staff failed to provide Resident # 45 or the resident's representative written notification when the resident was transferred to the hospital on [DATE]. Resident # 45 was admitted to the facility on [DATE] and a re-admission on 11/30/18 with [DIAGNOSES REDACTED]. Resident # 45's most recent MDS (minimum data set), a 30-day assessment with an ARD (assessment reference date) of 12/19/18, coded Resident # 45 as scoring a 9 (nine) on the brief interview for mental status (BIMS) of a score of 0 - 15, 9 (nine) - being moderately impaired of cognition for making daily decisions. The nurse's Progress Notes, dated 11/25/2018 for Resident # 45 at 11:53 p.m. documented the resident was transferred to the hospital emergency room for evaluation. The note further documented, Attempts made to contact RP (responsible party) on all 3 numbers. (Name of Transport) squad in, stated both (Name of two Hospitals) were on diversion. Call placed by EMT (emergency medical technician) to (Name of Hospital) ER (emergency room ) nurse, who stated they had no available beds but would accept resident with possible transfer to another hospital. Squad left with res en route to (Name of Hospital) at 2345 (11:45 p.m.). Further review of the clinical record failed to reveal any evidence that the responsible party was notified in writing of the hospital transfer. On 3/06/19 at 2:45 p.m., an interview was conducted with OSM #2 (Other Staff Member, Director of Social Services). OSM #2 stated she sends the Discharge/Transfer form to the responsible party, but that this only started in (MONTH) 2019. A review of the Discharge/Transfer Form which was documented as being created (MONTH) 2019, documented, I understand that I am being discharged /transferred from (facility). I understand the reason for discharge/transfer is: (two long lines provided for writing in the reason for the transfer) Responsible Party Signature: (long line provided for signature); Date: (line provided for date); Copy Given (a box to check for this option provided); Copy Mailed on: (a line provided for the writing in of the date the notice was mailed to the responsible party) This form was not utilized during the time of the above hospital transfer. On 03/06/19 at approximately 3:30 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 3, regional nurse consultant, were made aware of the findings. No further information was provided prior to exit. References: (1) An infection in the urinary tract. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm. (2) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (3) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm. (4) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. 3. The facility staff failed to evidence that Resident #153's responsible party was provided with written notification of the hospital transfer when the resident was transferred to the hospital on [DATE]. Resident #153 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #153's Minimum Data Set (MDS) was a significant change in status assessment with an Assessment Reference Date (ARD) of 1/15/19, and coded Resident #153 as severely impaired for cognitive skills for daily decision-making. A review of the clinical record revealed a nurse's note dated 2/15/19 at 12:45 p.m. that documented, 1:1 monitoring has continued since beginning of shift. at 1140-(Name of Doctor) in and spoke with md (medical doctor) re (regarding): transferring resident to more appropriate setting for safety of resident and other, and order written to go to (Name of hospital) ER (emergency room ) for psych (psychiatric) eval (evaluation) for possible admission re: behaviors. This writer left msg (message) for rp (Responsible Party) to return call to facility. resident was oriented that he was being sent to (Name of hospital) ER in (Name of town, state) by stretcher for eval (evaluation) and possible admit to hospital to help with his previous behaviors, resident smiled and said 'okay.' at 1150 spoke with (Name of transport staff) at (Name of transport ambulance) to transport resident to (Name of hospital) er. at 1225 2 attendants with (Name of transport ambulance) in facility and enroute via stretcher to (Name of hospital) ER at 1235. at 1242 report was given to (name of ER staff) rn (Registered Nurse) at (Name of hospital) er. Further review of the clinical record revealed a nurse's note dated 2/15/19 at 5:46 p.m., that documented, at 1400 rp returned call to facility and made aware resident was sent to (Name of hospital) ER for psych (psychological) eval with possible admit. rp was asked about holding residents bed at $195 per day, rp declined stating 'I dont {sic} have the money.' (Name of administrative director) aware. Further review of the clinical record failed to reveal any evidence that the responsible party was notified in writing of the hospital transfer. A review of the Discharge/Transfer Form which was documented as being created (MONTH) 2019, documented, I understand that I am being discharged /transferred from (facility). I understand the reason for discharge/transfer is: (two long lines provided for writing in the reason for the transfer) Responsible Party Signature: (long line provided for signature); Date: (line provided for date); Copy Given (a box to check for this option provided); Copy Mailed on: (a line provided for the writing in of the date the notice was mailed to the responsible party) The information regarding the mailing of notification of transfer to RP was not completed on the form. On 3/06/19 at 2:45 p.m., in an interview with OSM #2 (Other Staff Member, Director of Social Services) she stated that she sends the Discharge/Transfer form to the responsible party, but if the information is not completed regarding the mailing of notifying the RP of the transfer, I did not mail it. A review of the facility policy, Transfer or Discharge, Emergency documented, 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures e. Notify the representative (sponsor) or other family member . The policy did not specify that notification must occur in writing. On 3/06/19 at 6:36 PM, ASM #1 (Administrative Staff Member - the Administrator) was made aware of the findings. No further information was provided by the end of the survey. 4. Resident #92 was transferred to the hospital on [DATE]. The facility staff failed to provide written notification of the transfer to Resident #92 and/or the resident's representative. Resident #92 was admitted to the facility on [DATE]. Resident #92's [DIAGNOSES REDACTED]. Resident #92's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/18/19, coded the resident as being cognitively intact. Review of Resident #92's clinical record revealed the resident presented with a fever and nausea, and was transferred to the hospital on [DATE]. Further review of Resident #92's clinical record failed to reveal written notification of the transfer was provided to the resident and/or the representative. On 3/6/19 at 10:28 a.m., an interview was conducted with LPN (licensed practical nurse) #4 and RN (registered nurse) #1. LPN #4 and RN #1 was asked if nurses provide written notification to residents and/or their representatives when residents are transferred to the hospital. RN #1 stated they call the representative and send a written notice in a packet when residents are sent to the hospital. RN #1 stated he was not sure if written notice was provided when Resident #92 was transferred to the hospital on [DATE]. On 3/6/19 at 3:41 p.m., RN #1 confirmed he could not provide evidence that written notice was provided to Resident #92 and/or the representative when the resident was transferred to the hospital on [DATE]. On 3/6/19 at 4:50 p.m., ASM (administrative staff member) #1 (the administrator), ASM #3 (the regional nurse consultant) and ASM #4 (the regional vice president of operations) was made aware of the above concern. No further information was presented prior to exit. 5. The faciltiy staff failed to provide written notification to the resident and/or responsible party, of a facility initiated transfer for Resident #38 on 11/9/18. Resident #38 was admitted to the facility on [DATE] with a recent readmission on 11/21/18, with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 2/27/19, coded the resident as having both short and long term memory difficulties. The nurse's note dated 11/10/18 at 2:02 a.m. documented in part, Late entry for evening shift - Res (resident) rested well in bed, IV (intravenous) of NS (normal saline) infusing in rt (right) forearm .Noted with increased coughing episode at supper, only ate a few bites. RP (responsible party) in to visit. Attendants in to pick up resident for (Name of Hospital) for evaluation of lethargy and decreased intake. Review of the clinical record failed to evidence the resident and or the resident representative were provided written notification of the 11/10/18 hospital transfer. On 3/06/19 at 2:45 p.m., in an interview with OSM #2 (Other Staff Member, Director of Social Services) she stated that she sends the Discharge/Transfer form to the responsible party, but that this only started in (MONTH) 2019. Administrative staff member (ASM) #1, the administrator, ASM #3, the regional nurse consultant, and ASM #4, the regional vice president of operations, were made aware of the above findings on 3/6/19 at approximately 6:00 p.m. No further information was obtained prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 527.

2. Resident #1 was not provided supervision to prevent an elopement from the facility. Resident #1 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent 3.0 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/1/10 was an admission assessment. The resident was assessed with [REDACTED]. The following individuals, at the facility, were interviewed regarding the findings: Resident #1, the administrator, and the unit manager on the secured unit, who was a licensed practical nurse and will be identified as LPN #4. On 2/2/11 at approximately 8:45 a.m., Resident #1 was observed sitting in his room reading a newspaper. The resident's window was observed bolted shut with silver screws. As this surveyor was observing the resident's window, Resident #1 stated, "I used to be able to open that window but now I can't and I'm a mechanic." On 2/2/11 at approximately 9:00 a.m., the following notes were reviewed in Resident #1's clinical record: ? An Admission Assessment Note dated 10/28/10 ...."He wanders around the unit; looking for a way out..." ? A Nurses' Note dated 10/28/10 0945 (9:45 a.m.)...."Refused to let me assess him further stating he's not staying here. Sitting near nurse's station waiting to find a way out of here..." ? Nurses' Note dated 10/29/10 1400 (2:00 p.m.) "Just want to go home." ? Nurses' Note dated 10/30/10 0200 (2:00 a.m.) Resident awake at this time. Resident wanted to know how he could get out of here. He was told that he was here for safety. Resident stated that he was small enough to get out of the window in his room all he needed to do was knock the screen out..." The following Nurses' Note dated 12/8/10 were reviewed to include the following: ? "0030 (12:30 a.m.) "Charge nurse encouraged resident to go back to bed." ? "0230 (2:30 a.m.) CNA (certified nursing assistant) spoke c (with) resident as he walked through common area per his usual night time routine." ? "0330 (3:30 a.m.) Resident was up again CNA asked res (resident) what was wrong and he said nothing and he went back to bed." ? "0530 (5:30 a.m.) received phone call regarding resident being out of building at a home." ? "0730 (7:30 a.m.) Resident received back to building..." On 2/2/11 at approximately 11:07 a.m., LPN #4 was interviewed regarding the resident's unobserved exit from the facility through his bedroom window on 12/8/10. LPN #4 stated the resident did exit "out of his window" and that now all of the windows on the secured unit are locked. When interviewed and asked the reason for not locking the windows beforehand, when Resident #1 mentioned how he could exit the facility, LPN #4 stated that due to a "fire code" the facility could not put screws in the window; LPN #4 further stated that after the resident exited the facility, the Fire Marshall was called and he (the Fire Marshall) said it was "ok to put screws on the window." On 2/2/11 at approximately 11:15 a.m. further review of the resident's clinical record revealed an "Elopement Assessment" dated 11/1/10 to include the following under Risk Considerations: ? "Is this a new admission? Yes." Point value 1 ? Has made attempts to elope? No Point value 0 ? Ambulatory? Able to walk alone Point value 1 ? History of wandering? Yes Point value 1 ? Has been found "lost" wandering the building? Yes." Point value 1 "Conclusion with a total score of 4. The higher the score, the greater the elopement risk... Resident resides on a secured unit and has made no attempts of elopement." No further "Elopement Risk Assessments" were reviewed in the resident's clinical record. On 2/2/11 at approximately 3:30 p.m., LPN #4 was interviewed regarding Elopement Risk Assessments and Behavior Sheets prior to 11/1/10. LPN #4 stated, "That (the assessments that were in the clinical record) was it." On 2/2/11 at approximately 1:48 p.m., the administrator was interviewed regarding Resident #1's unobserved exit from the facility on 12/8/10. The administrator stated, "He's a very sweet man. I asked him why did he leave and if he knew how worried we were and he (the resident) said 'I just wanted to see if I could do it.' The administrator proceeded to state that she was very worried about him "but the windows are now locked in all the rooms." On 2/2/11 at approximately 5:35 p.m., during the end of the day meeting with the administrator and the director of nursing, the administrator stated in regards to Resident #1 exiting the facility, "I know, he just wanted to prove a point that he could do it." This is a complaint deficiency. Based on observations, resident interviews, staff interviews, facility document review, and clinical record review and in the course of complaint investigation, it was determined that the facility staff failed to provide 2 of 30 residents a safe environment with adequate supervision to prevent accidents (Residents #10 and #1); and failed to ensure assistive devices were maintained to be free of accident hazards. 1. Facility staff continued to seat Resident #10 in a geri-chair (a reclining type chair that locked preventing the foot rests to lower), despite repeated falls from the chair and multiple attempts to get out of the chair. Resident #10 sustained a fracture to her wrist during use of the device. 2. Resident #1 was not provided supervision to prevent an elopement from the facility. 3. Resident wheel chairs and geri-chairs were observed in the main dining area during lunch on 2/2/11. Six wheel chairs and four geri-chairs were observed to have cracks in the arm pads or seat cushions. The findings include: 1. Resident #10 was an [AGE] year old who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed an Initial Minimum Data Set (MDS) 2.0 version, with an Assessment Reference Date (ARD) of 07/22/2010. Under Section B-Cognitive Patterns-the resident was coded as having short and long-term memory problems and being severely impaired for daily decision making. Under Section C-Communication/Hearing Patterns-the resident was coded as usually making herself understood but rarely having the ability to understand others. Under Section E-Mood and Behavior Patterns-the resident was coded as being restless, insomnia and sad/pained expressions. Under Section G-Physical Functioning and Structural Problem-Resident #10 was coded as requiring limited assistance with one staff member for transfers. The resident was also coded as requiring extensive assistance of one with ambulation. The remainder of the Activities of Daily Living (ADLs) the resident was coded as being totally dependent on staff. Also in Section G for balance, the resident was coded as requiring partial physical support during the test; or stands (sits) but does not follow directions for test. Under Section H-Continence In Last 14 Days-the resident was coded as being incontinent for all or almost all of the time regarding bladder and bowel control. Under Section J-Health Conditions the resident was coded as having a fall in the past 30 days without sustaining a fracture. Further review of the resident's clinical record revealed a Quarterly MDS 3.0 version, with an ARD of 11/12/2010. The resident's cognitive status remained the same however, her patterns of behavior was additionally coded as wandering, socially inappropriate, and resisting care. Under Section G the resident was coded as requiring limited assistance by one person for ambulating in her room and on unit, eating independently after set-up, requiring extensive assistance with personal hygiene and bathing, and the resident was coded as using a cane and a wheelchair for mobility. Under Section H the coding indicated an improvement in her bladder and bowel control as only being incontinent frequently with extensive assistance for toileting by one staff member. Under Section J the resident was coded as having a fall in the past 30 days but no indication of the wrist fracture that she sustained on 08/30/10, as diagnosed by an x-ray found in the resident's clinical record dated 08/30/10. Review of the nurse's notes in the resident's clinical record recorded the following: 07/30/10, 15:10-"Resident at nurses station trying to get up unassisted in geri-chair at this time." 07/30/10, 10:00 pm-"Resident up in geri-chair until bed time, numerous attempts to get up unassisted: 1:1 supervision and tab alarm". 08/01/10, 14:45-"Resident up in geri-chair trying to get up unassisted. Resident sitg back in chair. Resident up at nurses station for close watch." 08/05/10, 14:30-"Up in geri-chair sitting up at times in geri-chair." 08/05/10, 10:00 pm-"up in geri-chair 1:1 supervision at nurses station, alert & verbal, baby doll provided for "hands on" activity-multiple attempts to stand unassisted." 08/06/10, 14:40-"Resident in geri-chair talking with staff at nurses station." 08/07/10, 14:35-"Both daughters in to visit today up in geri-chair." 08/08/10, 14:25-"Up in geri-chair." 08/10/10, 14:45-"Up in geri-chair trying to get up unassisted. Resident redirected to stop trying to get up unassisted." 08/11/10, 14:20-"Up in geri-chair. Resident still trying to get up without assistance." 08/12/10, 10:00 pm-"Behavior improving with increased med schedule; still attempts to get up unassisted before suppertime: re-direction is better with items baby doll and blanket and snack; supervised location daily at nurses station and tab alarm in place." 08/13/10, 14:30-"Resident walked 2 assist. Resident not trying to get up unassisted, very talkative. Reading the signs off of doors." 08/14/10, 15:30-"Resident found on floor in room sitting on buttocks against wall. States she needed to go to bathroom. Up to chair. No apparent injury. Taken to bathroom. Had medium sized BM." 08/14/10, 21:30-"Assisted to bed-Slept for awhile in geri-chair after before bed meds given." 08/15/10, 22:00-"Resident repeatedly trying to get up from geri-chair." 08/16/10, 10:00 pm-"Numerous attempts to stand from geri-chair." 08/17/10, 14:15-"Up in geri-chair at nursing station for close observation, tab alarm in place." 08/17/10, 6:00 pm-"Kept attempts to get up from chair." 08/18/10, 14:00-"Resident up in geri-chair trying to get up unassisted. Resident redirected to only get up with assist." 08/19/10, 13:50-"Up in geri-chair." 08/19/10, 6:00 pm-"Start antibiotic re: Urinary Tract Infection." 08/20/10, 14:10-"Up in geri-chair." 08/22/10, 14:20-"Up in geri-chair." 08/22/10, 10:00 pm-"active-standing up unassisted numerous times, 1:1 supervision in front of nurses station, alert & verbal" 08/24/10, 16:10-"Up in geri-chair." 08/27/10, 14:30-"Up in geri-chair trying to get up out of chair several times. Resident redirected to stay in chair." 08/28/10, 12:30-"Resident up in geri-chair. Geri-chair was reclined back. Resident sit up and chair as well. Resident stood up and fell back in front of chair scraping back on front of chair and found on buttocks. Resident has a scratch on left side of back. No treatment needed, no bruising at this time. Supervisor, MD, RP made aware. Resident redirected to only get up with assist." 08/28/10, 20:30-"Resident has tried to get up from geri-chair 3 or 4 times-tab alarm intact and closely monitored by staff. Did slap at Certified Nursing Assistant x 1 during ADLs." 08/29/10, 15:10-"Up in geri-chair." 08/29/10: ? 17:00-"Resident trying to get up from geri-chair. Reminded by staff to sit back. Tab alarm intact. Resident noted with swollen right wrist & some greenish to purple discoloration above right wrist or forearm. Also lateral forearm has protruding area but does not appear to be bone on palpation." ? 17:15-"Supervisor in to assess right wrist & forearm. Able to bend right (passive) wrist at this time without pain. MD made aware." ? 20:30-"Has tried numerous times to get up from geri-chair. Did get up 2 times." 08/30/10, 10:00 pm-"X-ray right upper extremity-results in-right fracture." Review of the X-ray results dated, 08/30/10 revealed the following documentation: "Views of the forearm and of the wrist are received and reveal and acute cortical fracture at the dorsal cortex of the distal radius only visible on the lateral projection. Otherwise, the wrist and the forearm are intact. There is osteoporosis. There is moderate osteoarthritis of the wrist. Impression: Acute cortical fracture at the dorsal cortex of the distal radius at the wrist as noted." The report further stated the physician and the responsible party were notified at 9:45 pm. A nursing note dated 08/31/11 at 3:45 pm, confirmed the resident was sent out to an Orthopedic Clinic for evaluation and returned. Further review of the nursing notes revealed the following entries: 08/31/10, 10:00 pm-"Very ornery, non-compliant to sit in geri-chair, up & down, hard to re-direct. Refused assist at meal time." 09/03/10, 14:00- "Resident still getting up unassisted. Resident redirected to stay in geri-chair and only get up with assist." 09/15/10, 16:50-"Resident found sitting on buttocks on floor of hallway in front of nurses station. Tab alarm intact and going off. Assisted by staff back into geri-chair." 09/16/10, 14:10-"Resident up in geri-chair. Resident to sit back in chair many times. Resident complied, no distress from previous fall." 09/17/10, 13:51-No distress from previous fall. Resident tab alarm in place up in geri-chair. Resident not trying to get up unassisted." The first note that addressed the resident's treatment was on 09/20/10 at 15:30- "Returned from Ortho appointment with consult to continue (rt) arm splint x 2 weeks." 11/12/10, 12:00-"Resident interview/assessment quarterly conducted. Resident exhibits short term/long term memory problem. Believes today is Sunday, January 2001. Complained of feeling "sad" at times. Receives antidepressant, antianxiety & antipsychotic meds. Requires supervision to total care with ADLs. She is frequently incontinent but she will use commode. Possible candidate for RNP (Restorative Nursing Program) B & B (bowel and bladder). Ambulates with RNP. Had fall in past 31-180 days. Gets up to geri-chair and attempts to get up." 12/24/10, 15:00-"Up in geri-chair. Slid out on floor observed by housekeeping staff." 12/25/10, 12:00-Up in geri-chair." 12/26/10, 14:30-"Up in geri chair." Review of the nurses notes revealed no further documented entries regarding Resident #10 attempting to exit the geri-chair. A further review of the Resident #10's clinical record did not reveal any assessment for the use of the geri-chair even though there were multiple notations of the device used over a 5 month period. (7/10-12/10). Review of the Physician order [REDACTED]. Validated physician orders [REDACTED]. 07/13/10-"Physical Therapy evaluation and treatment as indicated." 07/14/10-"Change to mechanical soft with pureed meats 4 gram sodium-straws on tray. Sit upright for all meals." 07/14/10-"Recommend Physical Therapy 3 times a week for 4 weeks to address: therapy treatment/activities, gait/balance training, NMR, wheelchair mobility, group activity, patient education and discharge planning." 07/18/10-"Order for tab alarm and fall mat re: safety. 07/19/10-:Ativan 0.25 milligrams by mouth twice a day for agitation." 08/30/10-X-ray of the right forearm and right wrist due to pain, swelling, bruising." Review of the Resident #10's care plan, last updated on 12/24/10, did not indicate the use of a geri-chair for any intervention or purpose. A review of the CNAs Resident Needs form dated 11/14/10, under section the section addressing Seating noted that the resident was to use a recliner, not a geri-chair for seating. An interview was conducted on 02/02/10 at 9:00 am with RN #1. When asked about the use of geri-chairs she stated "it is a nursing measure, geri-chairs are used for comfort and safety measures." When asked how it was for comfort measures RN #1 further stated, "They recline back and relax." An interview was conducted on 02/02/10 at 9:15 am with the Director of Nursing (DON). The DON was also asked if an investigation had been completed regarding the resident's fractured wrist. The DON stated, "No, we knew it happened during one of her falls." An observation of Resident #10 was made on 02/02/11 at 10 am. The resident was in her room in the geri-chair with the legs elevated watching television. An observation of Resident #10 was made on 02/03/11 at 10:30 am. The resident was in her room alone in the geri-chair with the legs elevated with the television on. An observation of Resident #10 was made on 02/03/11 at 2:00 pm. The resident was in her room talking with her roommate and the leg elevating device that causes the resident to be stationary in the chair was not raised. Administration was notified of findings on 02/03/11 at 3:00 pm prior to the decision making process and official exit. 3. Resident wheel chairs and geri-chairs were observed in the main dining area during lunch on 2/2/11. Six wheel chairs and four geri-chairs were observed to have cracks in the arm pads or seat cushions. At 3 pm on 2/2/11 the work order process was discussed with OTHER #2 (maintenance director). OTHER #2 stated that he was responsible for fixing wheel chairs and geri-chairs but not for identifying problems with the equipment. He explained that each nursing station has a work order book. He stated that staff has been trained to note any work order requests in these books. He stated that one of his staff picks up the work order books daily, usually after lunch. Upon review of the work order books, no requests for wheel chair or geri-chair maintenance were noted. OTHER #2 stated that wheel chair arm pads had recently been ordered. The administrator, DON, and corporate consultant were informed of the findings related to the wheel chairs and geri-chairs at the end of day exit on 2/3/11.