Every finding on record at Heritage Hall Lexington

Based on observation, staff interview, and facility documentation review, the facility staff failed to label and store medications appropriately in the one medication room and on one of two medication carts (pink hall cart). The findings included:On 8/26/25 at10:08 a.m., an observation/inspection was conducted of the medication storage room in the presence of licensed practical nurse #2 (LPN #2). Within the medication room storage cabinet with over-the-counter medications there was four full bottles of Oyster shell calcium 500 mg. Each bottle had 200 tabs each and all had an expiration date of 6/2025. Each bottle had a sticker that read [pharmacy name redacted] nurse consulting- medication expiring soon, please review. There were also two bottles of fiber laxative, each bottle had 90 capsules and were noted to have had an expiration date of 7/25. The medication storage refrigerator had an internal thermometer that was reading 26 degrees Fahrenheit. The nurse confirmed that this temperature would freeze the medications and immunizations contained in the fridge and was going to adjust the temperature gauge of the fridge. However, the thermometer was noted to have been cracked, and it was uncertain if it was accurate. According to the temperature log, it had been checked by the third shift nurse and was noted at 12:01 a.m., to have a temperature recorded of 38 degrees. LPN #1 was asked about the expiration date of medications and stated that if they have expired, they may lose their effectiveness. On 8/26/25 at 10:28 a.m., an inspection was conducted of one of the two medication carts. Licensed practical nurse #2 (LPN #2) was present during the inspection and confirmed that the cart being inspected was the pink hall cart. Within the medication cart was a vial of lidocaine hcl 1% that had been accessed and had no open date. LPN #2 said she knows it was opened last Tuesday but stated she was not the nurse that opened it. LPN #2 said it is important to date vial(s) when opened so that you know how long it is good for. LPN #2 said, I'm going to get rid of this because she is off of it now. Within the drawer that contained over-the-counter medications, a bottle of fiber laxative capsules was available for administration and had an expiration date of 7/25. LPN #2 confirmed the capsules were expired and stated, it was an infection control issue giving expired medications. When asked who is responsible to check dates of medications, LPN #2 said everyone is responsible to check as you go. On 8/26/25 at 3:30 p.m., an interview was conducted with the facility's director of nursing (DON). When asked about medication storage she explained that her medical records employee does the ordering of supplies and should be checking the dates of items in the medication storage room at least weekly. She stated that the nurses should be looking at medications in the medication carts daily. When asked about multi-use vials, the DON stated they should be labeled on the box and vial with the date opened, so that expiration dates can be determined. The facility policy titled, Medication Labeling and Storage, was reviewed. The policy read in part, . 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Medication Labeling: . 4. For over the counter (OTC) medications in bulk containers the label contains: a. the medication name, b. strength, c. quantity, d. accessory instructions, e. lot number, f. expiration date. 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 30 days unless the manufacturer specifies a shorter or longer date for the open vial. According to an additional facility policy titled, Medication Storage: Storage of Medication, which read in part, . 14. Outdated, contaminated, discontinued, or deteriorated medications are those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. On the afternoon of 8/26/25, the facility's administrator and director of nursing were made aware of the above findings.No additional information was provided.

Based on observations, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation failed to post grievance information and failed to ensure an accurate grievance process for one resident, Resident #30 (R30) out of a survey sample of 19 residents. The findings included:1.The facility failed to ensure that grievance forms were readily available to residents and failed to identify and communicate who the designated grievance officer was at the facility. On 8/26/25 at 1:45 p.m., an observation was made in the facility. There were no grievance forms available for residents to submit their concerns, and there was no posting of the grievance officer's name or contact information. On 8/26/25 at 2:00 p.m., a meeting was held with the resident council members. During the meeting, several residents stated they were not aware of who the grievance officer was or how to file a grievance. This had limited their ability to voice concerns and ensure grievances were addressed. On 8/26/25 at 3:49 p.m., an interview was conducted with the director of nursing regarding the grievance process. She stated she would have to defer to the administrator, as she was not sure how far he was from educating staff and residents about the new grievance process. She explained the new process involved staff entering grievances int the computer system, but residents could also give concerns to any staff member. She further explained that under the previous process, concerns were given to the department head, investigated, and a resolution provided. If the resident was not satisfied, another resolution would be sought. During the interview, the nurse consultant brought in a QR code (taken from the restroom posting) that residents could scan for grievances; however, this had not been communicated to the residents. Several residents were interviewed regarding the posting in their rooms. They stated that the posting only appeared to ask for general feedback about how they liked the facility and did not explain the grievance process. When asked if they had cell phones to scan the QR code, the majority of residents reported they did not have cell phones. On 8/26/25 at 4:05 p.m., an interview was conducted with the administrator regarding the grievance process. He stated a new grievance process had been implemented and that QR codes were placed in all areas of the facility and in resident rooms. He reported he had educated residents at a resident council meeting and informed them that he was the grievance officer. When asked to provide evidence that he attended the resident council meeting to provide this education, no evidence was provided. The administrator further acknowledged that, technology is great but not for this population, and stated he would request approval from corporate to return to a paper version of the grievance process. On 8/27/25 at 9:20 a.m., an interview was conducted with a certified nursing assistant, CNA#4 (CNA4). She stated residents tell her their issues, which she immediately reports to the nurse. She follows up with the assistant director of nursing or director of nursing to ensure it was addressed. The CNA4 said, we don't have paperwork back here to file a grievance. I don't know who the grievance officer is. I would assume the social worker. I have not been made aware of the new grievance procedure. She further stated there were QR codes in resident rooms, but she did not know what they were for. She recalled seeing QR codes in the bathroom and by the time clock, and at the facility entrance. CNA4 stated that she had never seen grievance forms available for residents or staff, nor had she seen the grievance officer posted. On 8/27/25 at 10:05 a.m., an interview was conducted with the staff scheduler, CNA#5 (CNA5). She stated she believed the administrator was the grievance officer. She reported that she would fill out a, Stop and Watch, paper if she needed to report something, which served as documentation that she informed the nurse, and she would then follow up with the administrator. She stated she believed grievance forms may be available at the nurse's station but was not sure. The CNA5 further stated she would go to the administrator to file a grievance. She acknowledged that QR codes were posted in the bathrooms but stated, No one has told me what they are for. I think they are for the family to file a survey, but not a grievance concern. They have been in the bathrooms since I started here last October. On 8/27/25 at 10:14 a.m., an interview was conducted with a licensed practical nurse, LPN#4 (LPN4). LPN4 stated there were grievance forms, but she thought they were completed only if a staff member removed another staff member. She stated she believed the administrator was the grievance office but was unsure. She reported she had not paid attention to whether grievance forms were available to residents and had never personally completed one. She stated she thought they might be kept near the front office but was not sure. LPN4 further stated she did not know if there was a posting identifying the grievance officer and had never seen one. On 8/27/25 at 10:23 a.m., an interview was conducted with the social service director regarding the grievance process. She explained that the old system used paper forms, which were submitted to department heads, investigated, and returned with a resolution. She stated the new system, implemented April 1st, was online and required scanning QR code with a cell phone to submit concerns. She stated staff could also key grievances into the system if residents reported them verbally. She acknowledged OR codes were intended for, survey questions, and required a cell phone to use. She stated the grievance process had been discussed with department heads and at resident council, but no evidence was provided of that education. The social worker reported that the administrator was the grievance officer and stated there was a posting in the hallway; however, when she walked to the hallway during the interview, no grievance officer posting was present. On 8/27/25, a review of a facility document titled, Resident and Family Grievance Policy. The policy stated residents and family members may voice grievances, and that the facility, will make prompt efforts to resolve grievances. The policy further stated: grievance official is responsible for overseeing the grievance process; notices of resident rights regarding grievances will be posted in prominent locations throughout the facility; residents and families may file grievances verbally, in writing, or anonymously; and contact information for the grievance official, including name, business address, mailing and email address, and phone number, will be available and posted in the facility. On 8/27/25, an end of day meeting was conducted with the administrator, director of nursing, and corporate staff. During the meeting they were made aware of the above concerns. No additional information was provided. 2. The facility did not implement an accurate grievance procedure for Resident #30 (R30). Diagnoses for R30 included degenerative disease of nervous system, carpel tunnel syndrome, muscle weakness, osteoarthritis, arthritis left shoulder and unsteady on feet. The most recent MDS was a quarterly assessment dated [DATE], assessed R30 as cognitively intact. Review of a grievance (written out by the administrator) dated 6/18/25 regarding an incident during a transfer to the bathroom by certified nurse assistant (CNA #4) for R30, indicated CNA #4 was rushed causing R30 to lose balance and hit her shoulder on the wall. The grievance documented that the director of nursing (DON) was aware of the incident had spoken to and provided education to CNA #4. On 8/27/25 at 4:30 p.m. during an end of day meeting, the director of nursing (DON) verbalized, being unaware of the incident until it was brought to her attention on 8/27/25. The DON verbalized being on vacation the week of the incident and did not educate CNA #4 as CNA #4 is an agency CNA and has not worked at the facility since the incident. The administrator verbalized that he thought the DON knew about the incident. The facilities Resident and Family Grievance Policy read in part, The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions [.]. No other information was presented prior to the exit on 8/28/25.

Based on staff interviews, facility documentation the facility staff failed to implement their abuse policy for prescreening potential employees for five of 25 records reviewed. The findings included:The facility failed to follow its abuse prevention and background check policies as evidenced by not obtaining reference checks for two employees, not completing registry checks for two employees, and hiring an employee with a felony barrier crime. On 8-27-25, an employee record review was conducted. During the review, it was identified that one employee had no reference checks completed, and another had two reference checks that were not completed. Two nurses had findings noted on their licenses, but the facility did not obtain information about those findings. Additionally, one dietary employee disclosed a felony barrier crime on his sworn statement, which was confirmed on his background check, and the facility hired him.On 8-27-25, the Business Office Assistant was interviewed regarding background checks and license verification. She stated background checks are completed to ensure there are no barrier crimes, and the sworn statement provides information and permission to conduct the background check. She explained that license verification involves ensuring the license is current, and if anything is noted on the license, she provides it to the Administrator and Director of Nursing to determine whether the individual can be hired. She stated a barrier crime is identified on the criminal background check, and if it is non-nursing and occurred more than seven years ago, the Administrator can sign off to allow the hire. She added that if the license verification shows 'yes,' she prints that page but does not access the detailed information.On 8-27-25, the Director of Nursing stated she expected the Human Resource staff to bring her the employee file if a license verification indicated yes, so she could review what was on the license. The Director of Nursing stated she had not been provided with any files to review.On 8-28-25, the Administrator provided his employee file for review. After reviewing the file, he was questioned about the lack of reference checks. The Administrator stated that he had given two references for the corporate office to call and acknowledged that they were not in the file. He stated he had text messages, if that would count, and that he would get in touch with the corporate office to see if they had the references. No additional information regarding reference checks for the Administrator was provided.On 8/28/25, A facility document titled, Abuse, Neglect, and Exploitation Prevention and Reporting, was provided. This policy states that no employee or otherwise engaged individual may be employed if they: 3. (a) have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (b) have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property; or (c) have a disciplinary action in effect against their professional license by a state licensure body as a result of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property. The policy further requires that background, reference, and credential checks be conducted on employees prior to or at the time of employment in accordance with applicable state and federal regulations. In addition, any person having knowledge that an employee's license or certification is in question should report such information to the Administrator.On 8/28/25, A facility document titled, Hiring Policy, was reviewed. The policy states that all applicants who receive a conditional offer of employment must undergo a background check, including, but not limited to, the Virginia State Police and the Virginia Department of Health Professions. All applicants must also have reference checks conducted, with a minimum of two reference checks documented in the personnel file, which may be completed via written or phone request. Pre-employment checklists and documents have been established to ensure consistent pre-employment inquiries and capture of information. The policy requires that all pre-employment documents and processes be completed before an official offer of employment can be made.On 8/28/25, another interview was conducted with the Business Office Assistant. She stated that the employee who was hired with a felony barrier crime was going to be terminated and that, according to her regional manager, this employee should never have been hired.On 8/28/25, the Administrator, the Director of Nursing, and Corporate Staff were made aware of the findings above. No additional information was provided.

Based on observation, staff interview and facility documentation review, the facility staff failed to store and prepare food in a sanitary manner in the main kitchen and the unit pantry, having the potential to affect many residents residing on one of one unit.The findings included:On 8/26/25 at 8:35 a.m., a tour and observations in the main kitchen was conducted in the presence of the dietary manager (DM). The dietary manager was asked about his expectation regarding the labeling of opened food items and showed the surveyor write-on labels that have the prepared date and use by date. The DM stated he is more concerned about the use by date being present. When asked what the importance of labeling food items was, the DM said, So you know what is fresh and what's not, so you don't kill somebody. Food can be dangerous. Observations of the walk-in freezer revealed there was a bag of opened meat balls that was wrapped in saran wrap that had no date of when it was opened or to be used by. There was also a bag of food items that the dietary manager identified as manicotti that had no dates to indicate when it was opened or to be used by. Observations in the dry storage room revealed a bag of opened spaghetti noodles that was wrapped in saran wrap. No date could be seen as to when it was opened, the dietary manager unwrapped the noodles and stated that he tore it [the date] off. Also observed was a bag of elbow macaroni that had no date. There was a bag of opened five pound bag of sweet cornbread muffin mix that was opened, handwritten on the bag was a date of 8/9, the dietary manager was unable to determine if it was an open or use by date. Observations of the stand-alone cooler revealed two bowls of items that were not labeled with the contents, prepared date or date to be used. The dietary manager identified the items as sliced tomatoes and banana cream pie. There was also a half of a cucumber that had part of the skin removed and was wrapped in saran wrap and had no date of when cut or to be used by. There was also a staff member's personal mountain dew bottle that had been opened but had no dates. The dietary manager said, That has no business being in there. At the food preparation table in the kitchen, there were bulk food containers. There was two bulk containers of food thickener that had an open date of 7/25 and a use by date of 1/25. The dietary manager was unable to explain the dates if it was July 2025 and January 2025 or July 25, 2025, and January 25, 2026. There were two bags of opened powdered sugar that had been opened, one had an open date of 6/26 and use by 7/26, that the dietary manager explained the dates were month and year [June 2026/July 2026]. The second bag of powdered sugar had no dates. There was a bag of brown gravy powder mix that had an open date of 5/4 and no use by date was noted. An opened bag of brown sugar had a handwritten use by date of 9/20. Following the above observations a discussion was held with the dietary manager who confirmed it was confusing and left a lot to interpretation with the dates observed on items. You were unable to know if it was an open or use by date, if the dates were noted as month and day or month and year. On 8/26/25 at 9:12 a.m., an observation was conducted in the pantry on the unit. In the cabinets where dry foods and snacks for residents were stored it was noted that a bag of hot dog buns was present and had a best by date of 8/20/25. There was also a bowl of corn flakes cereal that the label read, CF [corn flakes] 8/15; UB [use by] 8/23. On 8/26/25 at 10:45 a.m., the dietary manager was observed coming out of the pantry on the unit. He was asked to accompany the surveyor back into the pantry and was shown the expired hot dog buns and corn flakes that were beyond their use by date. He removed both items and said he didn't know where the hotdog buns had come from. A review of the facility policy titled, Dietary Departments Standard Operating Policies and Procedures/ Cost Containment-Food Storage: General with an effective date of 12/2017, was conducted. The policy read in part, . 6. All foods that have been opened and partially used shall be dated and sealed before returning to a storage area. The facility policy titled, Food Storage: Covering, Labeling, Dating Food, was reviewed. According to the policy, 1. All foods are to be dated upon receipt. The date label shall reflect when the food has been received. The date upon receipt should be recorded as dd/mm/yy. 2. Follow manufacturer expiration dates or 'use by dates', when available to determine when a food should be discarded. Once a food item has been opened, use by dates may not apply. 4. All food items that are not stored in their original containers must be stored in closed containers, secured and labeled. The label must identify the common name of the food if the food cannot be easily identified. The label must have the date the food was packaged or prepared and/or the expiration date. Expiration dates may be used, or the food storage chart guideline may be used to determine the expiration date. 5. When storing bulk foods, such as cereal, pre-packaged cookies, and condiments, store in plastic containers with tight fitting lids. All bins must be labeled and dated as in #4. 6. When removing a food from dry storage, check the date label and discard any food that has passed the expiration dates or use by dates or storage guideline dates. The policy regarding covering, labeling and dating of foods, went on to read, Refrigeration Storage, 1. All foods must be covered, labeled and dated with a date label. All food should be monitored each day to be assured that the foods will be used, consumed or discarded by the use by date or expired date. On 8/26/25 at 2:55 p.m., the facility administrator was made aware of the above findings. No additional information was provided.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to follow physician orders for two of nineteen residents in the survey sample (Residents #17 and #46).The findings include:1. For Resident #17, staff failed to accurately monitor fluid intake to ensure compliance with a physician ordered fluid restriction. Resident #17 (R17) was admitted to the facility with diagnoses that included end stage renal disease, metabolic encephalopathy, glaucoma, epilepsy, dysphagia, anemia and diabetes. The minimum data set (MDS) dated [DATE] assessed R17 with moderately impaired cognitive skills. R17's clinical record documented a physician's order dated 8/14/25 for a fluid restriction of 1500 ml (milliliters) per day due to end stage renal disease with instructions for 4 ounces (oz.) of fluid to be administered four times per day with medication administration and the remaining ounces served on the meal tray. On 8/26/225 at 11:32 a.m., R17 was observed in bed. There was a tall thermal mug, shorter thermal mug and two coffee mugs on the resident's over-bed table. R17 was interviewed at this time about the fluid restriction and the mugs observed on the bedside. R17 stated she did not know how staff tracked her fluid intake. R17 stated the tall and short mugs on her table had water in them and the coffee mugs had tea from her meal trays. R17's medication administration record for August 2025 documented 2 oz. to 4 oz. of fluid was administered four times per day with each medication administration as ordered. Intake records documented fluid intake with each meal ranging from 120 ml and 600 ml. There was no documentation in the clinical record regarding any other fluid intake and no daily summary reflecting the resident's total fluid intake each day. On 8/27/25 at 2:56 p.m., the licensed practical nurse (LPN #4) caring for R17 was interviewed about the fluid restriction. LPN #4 stated the 4 oz. ordered at each medication administration was documented on the medication administration record. Accompanied by LPN #4, R17's mugs/cups were observed on the over-bed table. R17 stated at this time that the girls filled her tall and short mug with water and that I drink when I want. LPN #4 stated the certified nurse's aides were supposed to enter fluid intakes from meals, but she was not sure if fluid intake between meals was tracked. On 8/27/25 at 3:05 p.m., the certified nurse's aide (CNA #1) caring for R17 was interviewed. CNA #1 stated she was not aware R17 was on a fluid restriction. CNA #1 stated she routinely filled the brown mug each shift as the resident requested. CNA #1 stated one beverage was usually provided on each meal tray. CNA #1 stated she entered the meal tray intake but did not enter fluid intake between meals. CNA #1 stated, I've never been told to keep up with her [R17's] intake. CNA #1 stated for residents on fluid restriction, all fluid intake was usually recorded. On 8/27/25 at 3:32 p.m., the director of nursing (DON) was interviewed about compliance with R17's ordered fluid restriction. The DON stated the physician ordered fluid restriction should have been included on the R17's bedside Kardex that CNAs referenced for care instructions. The DON reviewed R17's Kardex (dated 8/27/25) and stated she did not see the fluid restriction listed on the Kardex. The DON stated the resident's supplemental fluid intake should have been monitored in addition to fluids provided on the meal tray and medication pass. The DON stated she reviewed fluid intakes for those residents with restrictions but that R17's between meal intakes had not been monitored or included in the totals each day. This finding was reviewed with the administrator, director of nursing, assistant director of nursing and regional nurse consultant during a meeting on 8/27/25 at 4:30 p.m. with no further information provided prior to the end of the survey. 2. Resident #46 did not receive a bariatric bed as ordered by the physician. Diagnoses for Resident #46 (R46) included: respiratory failure, anxiety, COPD, severe morbid obesity, and fibromyalgia. The most recent MDS (Minimum Data Set) was a quarterly dated 7/23/25, R46's BIMS score was 14, indicating cognitively intact. On 8/26/25 at 10:21 a.m. R46 was interviewed. R46 verbalized that the facility had ordered a Bariatric bed a month ago or so and has not gotten the bed yet. R46 expressed that the current bed is uncomfortable and the controls along with trying to reach things on the bedside table are difficult. Review of R46 physician's orders documented an order (dated 6/10/25) that read Bariatric Bed. Review of R46's care plan indicated a Bariatric bed was in place. On 8/28/25 at 11:00 a.m. the director of nursing (DON) and nurse consultant observed R46's bed. The DON said that the bed R46 was currently in was not a Bariatric bed and would look into the concern. On 8/28/25 at 11:30 a.m. The DON verbalized that she was unsure if the bed had been ordered and was unaware of the physician's order for the bed. The DON said that the facility has a Bariatric bed, but if it was in use then the supply clerk would order a bed. The DON said that the supply clerk was not at the facility currently and was unable to be reached. The DON said R46 did not want a Bariatric bed at this time but expressed understanding regarding the physician order had been in place since June 2025. No other information was provided prior to the exit conference on 8/28/25.

Based on staff interview, facility document review and clinical record review, the facility staff failed to document response to a pharmacy recommendation for one of nineteen residents in the survey sample (Resident #23).The findings include:Resident #23 (R23) was admitted to the facility with diagnoses that included Parkinson's disease, diabetes, chronic kidney disease, atrial fibrillation, dementia, obstructive sleep apnea, diabetes, major depressive disorder, anxiety, dysphagia, cognitive communication deficit, hypertension and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R23 with short and long-term memory problems and severely impaired cognitive skills.R23's clinical record documented a physician's order dated 12/9/24 for trazodone 25 milligrams each afternoon for agitation. R23's medication administration records for December (2024) and January (2025) documented the trazodone was administered each day at 5:00 p.m. R23's clinical record documented a pharmacy recommendation dated 1/2/25 regarding the trazodone. The recommendation documented, .This resident has a medication that has a side effect of increased sedation. The trazodone order is being administered at 5 PM daily. This increased sedation could lead to a fall. Recommend to monitor carefully and consider changing the time to bedtime unless clinically contraindicated.A hand-written note by the assistant director of nursing (ADON) dated 1/8/25 was documented on the recommendation sheet stating, .Given specifically @ 1700 [5:00 p.m.] for agitation. See MD [physician's] note 12/9/24 . The clinical record documented no physician response to the recommendation to change the trazodone administration time to bedtime. The nurse practitioner (NP) assessed R23 on 1/3/25 and 1/15/24 and made no mention or reference to the pharmacy recommendation.On 8/27/25 at 1:38 p.m., the ADON (LPN #3) was interviewed about a response to R23's pharmacy recommendation on 1/2/25. The ADON stated she would have reported the recommendation to the NP. When asked about the reference to the NP note that was made prior to the recommendation, the ADON stated if she wrote that note (1/8/25), she would have asked the NP, and the NP responded that she already addressed it in the 12/9/24 note. On 8/27/25 at 2:15 p.m., the director of nursing (DON) was interviewed about a documented response to the 1/2/25 pharmacy recommendation. The DON stated recommendations designated for the providers were routinely sent to them for response. The DON stated the ADON routinely handled the recommendations including getting responses to recommendations as required. The DON stated nursing should have contacted/notified the provider for clarification and documented if the recommendation was wanted or denied.8/27/25 at 3:56 p.m., the nurse practitioner (NP - other staff #3) caring for R23 was interviewed about the trazodone recommendation. The NP stated the trazodone was prescribed at 5:00 p.m. because the resident's agitation increased around that time each day. The NP stated she remembered a conversation about wanting the administration time to stay at 5:00 p.m. but she did not know if anything was documented specifically about the recommendation.The facility's policy titled Medication Regimen Review and Reporting (dated 1/2024) documented, .Resident-specific MRR [medication regimen review] recommendations and findings are documented and acted upon by the nursing care center and/or physician .For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record .This finding was reviewed with the administrator, director of nursing, assistant director of nursing and regional nurse consultant during a meeting on 8/27/25 at 4:30 p.m. with no further information presented prior to the end of the survey.

Based on staff interview, clinical record review, facility documentation reviews the facility staff failed to obtain labs per physician orders for one resident, Resident #9 (R9) out of a survey sample of 19 residents. The findings included:The facility did not obtain R9's lab the day it was ordered.On 8/28/25, an interview was conducted with the director of nursing (DON) regarding R9's lab work. The labs were scheduled to be completed on 8/25/25. The DON stated that, unfortunately, the lab scheduled for 8/25/25 was not obtained that day and there were no results available. The responsible person and physician were notified, and the lab was obtained today.On 8/28/25, a clinical record review was conducted for R9. The review revealed a physician's order dated 8/25/25 to obtain a PT-INR (pro-time/international normalized ratio). The resident's care plan included a directive to obtain labs as ordered.On 8/28/25, facility documentation titled Lab and Diagnostic Test Results was reviewed. The policy states that the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. Staff are responsible for processing test requisitions and arranging for tests. The laboratory, diagnostic radiology provider, and other testing sources are required to report test results to the facility. The physician may be notified by phone, fax, voicemail, email, mail, pager, or telephone message to another person acting as the physician's agent. Facility staff are instructed to document when, how, and to whom the information was provided in the residents record.On 8/27/25, an end of day meeting was conducted with the administrator, director of nursing, and corporate staff. During the meeting they were made aware of the above concerns.No additional information was provided.

Based on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to provide therapeutic diet per physician's orders for one resident, Resident #36 (R36) out of a survey sample of 19 residents. The findings included:R36's meat was not served moistened with gravy or sauce per physician orders.On 8/27/25 at 8:56 a.m., R36 was observed during the breakfast meal. His sausage was served without gravy or sauce and appeared dry. His meal ticket read: Regular, Mechanical Soft, Ground Meats, and ground meat with gravy. On 8/27/25, R36 was interviewed and repeatedly pointed at the sausage, saying no, no. His responsible person was also interviewed and stated that the only issue she had with the facility was the food, explaining that he does not eat well, the meals need to be more resident-centered, and the meats are dry, which he does not like.On 8/27/25, an interview was conducted with a certified nursing assistant, CNA #6 (CNA6). She was unsure about the gravy but acknowledged that if it is listed on the ticket, it should be provided. On 8/27/25, an interview with the Dietary Manager revealed that when the ticket specifies meat with gravy, it means the meat should be moistened. He stated that while sausage is naturally moist from grease, the ticket specifically said gravy or sauce, so it should have been served that way. He also stated meal tickets should be followed as they are based on physician orders.On 8/27/25, a clinical record review was conducted for R-36. His physician's orders included a mechanical soft diet with meats served with gravy or sauce and all drinks to be served in coffee mugs with meals. Review of his comprehensive care plan also reflected a therapeutic diet of mechanical soft with gravy or sauce on meats.On 8-27-25, an end-of-day meeting was held with the Director of Nursing, the Administrator, and corporate staff. They were made aware of the above concerns, and no additional information was provided.No additional information was provided.

Based on observation, resident interview, staff interview, clinical record review the facility staff failed to provide assistive devices with meals for one resident, Resident #36 (R36) out of a survey sample of 19 residents.R36's drinks was not in coffee mugs with his meals.On 8/27/25, R36 was observed during the breakfast meal. He did not have his fluids served in coffee mugs. His meal ticket read: Regular, Mechanical Soft, Ground Meats, Coffee mugs - put drinks in coffee mugs, and ground meat should have gravy on the meat. On 8/27/25, an interview was conducted with R36 regarding his difficulty picking up the glass of milk. He stated, yes, need handles.On 8/27/25, an interview was conducted with a certified nursing assistant, CNA #6 (CNA6). She stated that if the meal ticket indicates drinks in coffee mugs, then they should be served that way. On 8/27/25, R36 was interviewed and repeatedly pointed at the sausage, saying no, no. His responsible person was also interviewed and stated that the only issue she had with the facility was the food, explaining that he does not eat well, the meals need to be more resident-centered, and the meats are dry, which he does not like. An interview with the Dietary Manager revealed that when the ticket says all drinks are in coffee mugs, they must be served in coffee mugs, and tickets should be followed as they are based on physician orders.On 8/27/25, a clinical record review was conducted for R-36. His physician's orders included a mechanical soft diet with meats served with gravy or sauce and all drinks to be served in coffee mugs with meals. Review of his comprehensive care plan did not reflect to have all drinks served in coffee mugs with R36's meals.On 8-27-25, an end-of-day meeting was held with the Director of Nursing, the Administrator, and corporate staff. They were made aware of the above concerns, and no additional information was provided.No additional information was provided.

Based on observation, staff interview and facility document review, the facility staff failed to follow infection control practices for hand hygiene on one of four units (Sunset Drive).The findings include:A medication pass observation was conducted on 8/27/25 at 8:00 a.m. with licensed practical nurse (LPN #4) administering medications to Residents #42 and #2. After preparing and administering medication to R42, LPN #4 washed her hands at the room sink. After washing hands, LPN #4 directly touched the faucet handle to turn off the water, prior to drying her hands on with a paper towel. LPN #4 then prepared and administered medications to Resident #2. On 8/27/25 at 8:11 a.m., LPN #4 was interviewed about directly touching the faucet handle after hand washing. LPN #4 stated, I was probably nervous.On 8/27/25 at 8:34 a.m., the director of nursing (DON) and infection preventionist was interviewed about the observed hand washing. The DON stated after washing hands for approximately 20 seconds, hands should be rinsed, dried and the water turned off with use of a dry paper towel. The DON stated nurses were not supposed to directly contact the faucet handles after washing hands.The facility's policy titled Handwashing/Hand Hygiene (revised August 2019) documented, .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . This policy listed the procedure for handwashing as, .Wet hands first with water, then apply an amount of product .Rub hands together vigorously for at least 20 seconds .Rinse hands with water and dry thoroughly with a disposable towel .use towel to turn off the faucet .This finding was reviewed with the administrator, director of nursing, assistant director of nursing and regional nurse consultant during a meeting on 8/27/25 at 4:30 p.m. with no further information provided prior to the end of the survey.

Based on observation, resident interview, staff interview, clinical record review, facility documentation the facility staff failed to administer oxygen per physician's orders for one resident, Resident #1 (R1) out of a survey sample of 19 residents. The findings included:The facility was not following physician's orders for R1's oxygen therapy.8/26/25 at 9:00 a.m., an observation was made of R 1's oxygen set at 8.5 liters. On 8/27/25, an observation in the morning showed her oxygen was set at 9 liters. Later in the afternoon of 8/27/25, her oxygen was observed to be set at 10 liters. 8/27/25 at 9:00 a.m., an interview was conducted with R1 about her oxygen therapy. When asked about her oxygen she said, it too much I think sometimes. They put that thing on my finger and then turn the knobs.08/27/2025 9:12 a.m., R1's oxygen was observed to be set to 9 liters per minute. An interview was conducted with licensed practical nurse, LPN#6 (LPN6). LPN6 stated if R1's saturation levels fell below 88%, the oxygen may be increased to 10 liters per minute. She reported that R1's oxygen saturation level was checked at 5:00 a.m., that morning and was 97%. LPN6 verified that R1's oxygen was not set correctly and should be at 8 liters per minute. She then checked the oxygen saturation again, and it was 94. On 8/27/25, a review of R1's clinical record was conducted. R1's care plan reflected that oxygen should be administered at 8 liters per minute via high-flow nasal cannula to maintain oxygen saturations at 88%. It also included instructions to check pulse oximetry every four hours and stated that if saturations fell below 88%, oxygen could be increased to 10 liters per minute until saturations were above 90%. R1 had physician orders that were written on 7/24/25 to be administered at 8 liters per minute via high-flow nasal cannula to maintain oxygen saturations at 88% and check pulse oximetry every four hours and stated that if saturations fell below 88%, oxygen could be increased to 10 liters per minute until saturations were above 90%.On 8/27/25, facility documentation titled, Oxygen Administration, was reviewed. The policy states that the purpose of this procedure is to provide guidelines for safe oxygen administration. It instructs staff to verify that a physician's order is in place, review the physician's order or facility protocol for oxygen administration, review the resident's care plan to assess any special needs, and assemble the necessary equipment and supplies prior to administering oxygen. On 8/27/25, an end of day meeting was conducted with the administrator, director of nursing, and corporate staff. During the meeting they were made aware of the above concerns.No additional information was provided.

Based on resident interview, staff interview, and clinical record review, the facility failed to notify and thoroughly investigate an incident during toileting for one of nineteen resident's, Resident #30 (R30).The findings include: Diagnoses for R30 included degenerative disease of nervous system, carpel tunnel syndrome, muscle weakness, osteoarthritis, arthritis left shoulder and unsteady on feet. The most recent MDS was a quarterly assessment dated [DATE], assessed R30 as cognitively intact. Section GG indicates R30 needs supervision for toileting, partial to moderate assistance for sit to stand. A 6/4/25 MDS indicates partial to moderate assistance in lower body dressing, and partial to moderate for sit to stand and supervision or touching for toilet transfer. On 8/26/2025 at 1:51 p.m. R30 was interviewed. During the interview R30 verbalized falling about a month prior while being helped to the bathroom by a certified nursing assistant (CNA). R30 said that the CNA (identified as CNA #4) was asking R30 to pull up her pants while CNA #4 was supporting R30. R30 verbalized that she had lost her balance and fell against the wall and then sat down on the commode. R30 said her shoulder started hurting the next day.Review of R30 clinical record did not evidence any progress notes or assessments by the nursing staff on 6/17/25.Review of a progress note dated 6/18/25 by the nurse practitioner read in part in part The patient reports onset of right shoulder pain after a transfer incident yesterday afternoon/evening. A CNA assisted her to the bathroom, during which she had difficulty with the transfer and hit her right shoulder against the wall. She denies falling during the incident. Since then, she has experienced mild soreness in the right shoulder, which persists today. The pain is not severe and is only mildly noticeable when the shoulder is in extension with the arm overhead. Several weeks ago, she experienced left shoulder pain, which was effectively managed with Tylenol and lidocaine. She is currently working with physical therapy. On 8/27/25 the administrator was asked to see any incident reports related to R30's incident on 6/17/25.On 8/27/25 at 1:15 p.m. the director of nursing (DON) verbalized, being unaware of the incident until it was brought to her attention on 8/27/25. The DON verbalized being on vacation the week of the incident. The DON said that if an incident occurs it should be reported to the nurse on the floor and an incident report would have been filed. The DON presented a staff list of nurses and CNA's working on the day of the event and identified CNA #4 (agency CNA) assigned to R30 on the day and time frame of R30's incident.An interview was conducted on 8/27/25 with two CNA's (2 and #3) that are assigned to R30 consistently. Both CNAs were not aware of any incident regarding R30 on 6/17/25. Both CNAs expressed that R30 needed help pulling down and up her pants after using the bathroom and they would do this task while R30 supported herself using the grab-bar in the bathroom. License practical nurse (LPN #5), and registered nurses (RN #1 and RN #2) were working the day of the incident. Were contacted via telephone and all verbalized being unaware of an incident regarding R30.On 8/27/25 at 3:50 p.m. the nurse practitioner (other staff, OS #3) was interviewed. OS #3 verbalized while in R30's room on 6/18/25 working with R30's roommate, R30 verbalized that her shoulder was hurting and explained that during a transfer to the toilet R30 had lost balance and hit her shoulder against the wall. OS #3 explained that R30 was assessed at this time and did not find anything abnormal but did have some pain when moving her arm. OS #3 said R30 did have a diagnosis of arthritis and felt that the hit to the shoulder could have set off some pain and soreness to the area. OS #3 said that when R30's pain became persistent an x-ray was completed and showed no fracture or concerns, R30 was also ordered therapy to help with pain and mobility. When asked about notifying nursing staff regarding what was reported to her by R30, OS #3 verbalized, she thought the staff already knew about the incident. On 8/27/25 at 4:30 p.m. during an end of the day meeting with the facility staff the above information was presented. At this time the administrator verbalized that a grievance was completed on 6/18/25 regarding this incident and presented the grievance. The grievance indicated that R30 told her daughter (who works at the facility as a human resource manager, OS #4) about the incident and described the incident as CNA #4 was rushing with R30's toileting. On 8/27/25 at 5:00 p.m. OS #4 was interviewed. OS #4 verbalized being R30's daughter and had checked on R30 on 6/18/25. OS #4 said that R30 expressed that she (R30) felt the aide was rushing to help R30 in the bathroom and R30 hit her shoulder on the bathroom wall. OS #4 said that she filed a grievance with the administrator and asked that CNA #4 no longer be assigned to her mother. OS #4 said that R30 does try to do things herself and feels that R30 sometimes doesn't know her inability. Attempts were made to contact CNA #4 but were unsuccessful.No other information was presented prior to the exit on 8/28/25.

Based on observations, resident interview, staff interview, clinical record review, facility documentation reviews the facility staff failed to review and revise comprehensive centered care plans for two residents, Resident #10 (R10) and Resident #36 (R36) out of a survey sample of 19 residents. The findings included: 1.The facility failed to update R10's comprehensive care plan to reflect his current condition. The care plan continued to identify a Stage 4 pressure injury after the wound had healed and was no longer present.On 8/26/25 at 3:28 p.m., an interview was conducted with R10. The resident stated that he did not have any open wounds and that previous wounds had healed. On 8/27/25 at 9:00 a.m., an interview was conducted with the director of nursing (DON). The DON confirmed that the resident's wound was healed and acknowledged that the care plan was incorrect. The DON stated her expectation was for staff to revise care plans to reflect current conditions.On 8/27/25, a clinical record review of R10's was conducted. The care plan, revised on 5/9/25, indicated that he had a Stage 4 pressure ulcer. The Minimum Data Set (MDS), completed on 6/18/25, documented that he had no pressure wounds. According to the clinical record, the wound healed in March 2025.On 8/27/25, an end of day meeting was conducted with the administrator, director of nursing, and corporate staff. During the meeting they were made aware of the above concerns.2.R36's comprehensive care plan did not reflect the use of assistive devices during meals.On 8/27/25 at 8:15 a.m., an observation was made of R36's lunch meal. R36 liquids were not provided in coffee mugs according to his meal ticket. He was observed to have difficulty picking up the glass of milk. On 8/27/25 at 9:20 a.m., an interview was conducted with R36 regarding his difficulty picking up the glass of milk. He stated, yes, need handles.On 8/27/25, a clinical record review was conducted for R36. The record contained a physician's order dated 8/26/25 for all drinks to be provided in coffee mugs. During the review it was noted that his comprehensive care plan did not reflect the use of assistive devices with meals, coffee mugs, to support his strengths and ability to consume liquids safely.On 8/28/25 a facility document titled, Care Plans Comprehensive Person Centered, was reviewed. The policy states that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and is developed and implemented for each resident. 7. e. the policy specifies that care plans should reflect currently recognized standards of practice for problem areas and conditions. Under number 11, the policy stated that assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition changes.On 8/28/25 at 11:30 a.m., the administrator, director of nursing, corporate staff were made aware of the above concerns.No additional information was provided.

Based on staff interview and clinical record review, the facility staff failed to provide a complete and accurate clinical record for one of three residents in the survey sample (Resident #3, R3). The findings include: R3's ADL (activities of daily living) support logs and food intake logs were not documented on multiple times during the month of April 2023. According to R3's clinical record, diagnoses for R3 included: Post surgical hip replacement, urinary tract infection, and venous thrombosis. The most current MDS (minimum data set - assessment tool) was a 5 day admission assessment with an ARD (assessment reference date) of 3/31/24, which assessed R3 as being cognitively intact. Review of R3's ADL's for the month of April 2023, particularly eating performance, personal hygiene support, and toilet use were reviewed, between 4/1/23 and 4/28/23 (R3 discharged on [DATE]). The Eating performance section indicated of 56 opportunities to document eating support, 37 opportunities had not been documented. The Personnel hygiene support section indicated of 84 opportunities to document care, 39 opportunities had not been documented. The Toilet use support section indicated of 84 opportunities to document care, 38 opportunities had not been documented. Review of meal percentage intake log (also for April 2023) indicated of 84 opportunities to document, 59 opportunities had not been documented. On 10/15/24 at 2:30 p.m. the above information was presented to the administrator, who also reviewed the documentation. The administrator verbalized awareness and said that training needed to be done. The administrator also verbalized not being employed at the time of this concern. No other information was presented prior to exit conference on 10/16/24.

Based on staff interview, resident interview, facility document review, and clinical record review, the facility staff failed to provide timely toileting assistance for one of three residents in the survey sample (Resident #3). The findings include: According to the clinical record, Resident #3 (R3) was admitted to the facility with diagnoses that included femur fracture, urinary tract infection, degenerative disc disease, gastroesophageal reflux disease, and protein-calorie malnutrition. The minimum data set (MDS - assessment tool) dated 3/31/23 assessed R3 as cognitively intact and as occasionally incontinent of bowel and bladder. R3's clinical record documented a nursing note dated 4/22/23 at 10:48 p.m. stating, At approx [approximately] 2110 [9:10 p.m.] this nurse answered residents call light, resident reported her call light had been on for over an hour. Resident stated she needed assist to bathroom that she has soiled herself. This nurse told resident she would get the cna to assist her. (sic) R3's plan of care (dated 4/6/23) documented the resident required the assistance of one person for activities of daily living (ADLs) including toileting. Goals in providing ADL care were documented as, Resident will continue to receive assistance as needed in a timely manner . R3's ADL record for 4/22/23 was blank for the evening shift (2:00 p.m. until 10:00 p.m.) with no indication that toileting and/or hygiene assistance was provided. On 10/15/24 at 4:30 p.m., the assistant director of nursing (ADON - administration staff #3) was interviewed about R3's delayed call bell response documented on 4/22/23. The ADON stated that she worked as a floor nurse during R3's stay. The ADON reviewed the as-worked schedule and stated the evening shift CNA [certified nurses' aide] worked on 4/22/23 until 10:00 p.m. Reviewing the ADL documentation, the ADON stated R3's activities of daily living records documented no toileting assistance and/or hygiene provided during the evening of 4/22/23. On 10/16/24 at 8:45 a.m., the resident council president (Resident #4) was interviewed about call bell response and delayed assistance with toileting. The council president stated there were comments in the council meetings at times about slow call bell response. The council president stated most bells were answered within 10 to 15 minutes but there were times when it took up to 30 minutes. When asked about call bell response during April 2023, the council president stated she did not remember exactly what was going on then, but that current call bell response was much improved from a year ago and had improved with the current administration. On 10/16/24 at 9:30 a.m., the administrator was interviewed about R3's delayed call bell response/toileting assistance documented on 4/22/23. The administrator stated there was no toileting assistance documented for R3 on the evening of 4/22/23. The administrator stated he was not working in the facility in April 2023, but he found no documented follow up and/or actions taken in response to the delayed care. The administrator stated the entire care team was expected to respond to call bells and provided needed care in a timely manner. On 10/16/24 at 10:05 a.m., the director of nursing (DON) was interviewed about the documented care delay for R3 on 4/22/23. The DON stated that she was not working in the facility during R3's stay. The DON stated that she expected staff to respond to call lights and requests for assistance within 3 to 5 minutes, with the goal of no lights unanswered beyond 10 minutes. The DON stated the delayed response to R3's call light documented on 4/22/23 was unacceptable. The DON stated staff working should have acted promptly to provide needed assistance and should have documented follow up regarding the reported concern. The nurse that documented R3's note on 4/22/23 regarding delayed call bell response was not available for interview, as she no longer worked at the facility. Resident council meeting minutes were requested but had not been retained from the March/April 2023 meetings. The facility's policy titled Activities of Daily Living (ADLs), Supporting (revised March 2018) documented, .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . This finding was reviewed with the administrator, DON, and regional nurse consultants during a meeting on 10/16/24 at 11:00 a.m., with no further information provided prior to the end of the survey.

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure one of 17 residents (Resident #54) was free from unnecessary medications. Resident #54 was administered her roommate's medications in error and was transferred to hospital, where she required treatment. This indicated harm. The findings were: Resident #54 was admitted to the facility with diagnoses, including but not limited to: unspecified kidney injury, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and dementia. The MDS (minimum data set) that was completed for Resident #54 was an OBRA Admission Assessment with an ARD (assessment reference date) of 07/02/2021. Resident #54 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record was reviewed on 09/20/2022 beginning at approximately 8:30 a.m. The progress note section was reviewed and contained the following: 07/02/2021 10:48 AM During AM medication administration, rsd (resident) was administered wrong medications. Rsd VS (vital signs) obtained. 135/79, 72. 98.2, 18, O2 (oxygen) 96% on RA (room air), family in room at time. MD notified of error. Family requested to send rsd to ED (emergency department) (Name of hospital). 911 activated and report called to ED. The facility incident report was presented at approximately 1:30 p.m. and contained the following: Incident Date: 07/02/2021 Time: 1000 (10:00 a.m.) Describe Injury: Med. (medication) error Narrative of incident and description of injuries: During AM med. (medication) Administration rsd received wrong meds. VS: 135/79, 72, 18, 98,.2, O2 98%, family in room and requesting be sent to ED. Report called to ED. Two witness statements dated 07/02/21 were attached to the Incident report. The first contained the following: This Nurse called in report to (Name of hospital) in regards to the wrong medications given to the pt (patient). Medications as followed: [MEDICATION(S)] 7.5 mg (antihypertensive) * Vitamin C 1,000 mg (supplement/vitamin) * Calcitrol 0.25 mg (supplement) * [MEDICATION(S)] 6.75 mg (antihypertensive) * [MEDICATION(S)] 0.2 mg (antihypertensive) * Vitamin B-12 1000 mcg (supplement/vitamin) * [MEDICATION(S)] 2.5 mg (anticoagulant) * Famatodine 20 mg (Given to decrease stomach acid) * Senna-S 8.6-50 mg (stool softener) * Sevelamer HCL 800 mg (mineral binding agent) * ED nurse stated that none of these medications were of great concern and there was probably nothing they could do, but they would monitor her BP. *NOTE drug indications in () were not part of the witness statement but added for clarification/information. The second witness statement, written by the nurse who made the medication error contained the following: During AM med. Administration @0920 (9:20 a.m.) rsd was given wrong meds while sitting in the hallway. First day on this hallway with this pt, and I thought she was her roommate .Daughter sitting in doorway & notified that rsd received wrong meds & requested that she be sent to ED for eval (evaluation). Daughter was very understanding & stated to me that it was okay, don't be upset we all make mistakes, and no one is perfect. Rsd with no s/s (signs/symptoms) of distress or c/o (complaints of) discomfort, then obtained VS: 135/79, 72, 98.2, 18, O2 96%. EMS (emergency medical services) arrived @ 0945 (9:45 a.m.) Along with the incident report was a MEDICATION ERROR/OMISSION REPORT which contained the following: Wrong medication .medications administered in error: [MEDICATION(S)] 20 mg, Amolidipine 7.5 mg, Vitamin C 500 mg, Calcitrol 0.25 mg, [MEDICATION(S)] 6.25 mg, [MEDICATION(S)] HCL 0.2 mg, Vitamin B-12 500 mcg (2 tabs), [MEDICATION(S)] 2.5 mg, Famatodine 20 mg, Senna S 8.6-50 mg, Sevelamer HCL 800 mg Physician notified at 0930 (9:30 a.m.) .date 7/2/21. Physician Comments: None, family in room, requested rsd go to hospital . The facility policy for medication administration contained the following: General Dose Preparation and Medication Administration .Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Facility staff should: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident .During medication administration, facility staff should take all measures required by facility policy and applicable by law, including, but not limited to the following: Identify the resident per facility policy. On 09/20/2022 at approximately 4:00 p.m., the nurse who made the medication error (RN #3) was interviewed over the phone. RN #3 was asked if she remembered the medication error and if so what had happened. RN #3 stated, I was an LPN (licensed practical nurse) then .the resident was sitting in the doorway to her room. She and her roommate were new admissions .I gave her, her roommate's meds. On 09/21/2022 at approximately 9:30 a.m., the above information was discussed with the DON (director of nursing), the ADON (assistant director of nursing), the nurse consultant, and the administrator. No further information was presented prior to the exit conference on 09/21/2022. This is a complaint deficiency.

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to follow professional standards of quality for one of 17 residents in survey sample (Resident # 54). Nursing staff did not follow professional standards of clinical practice during medication administration. Resident #54 was not properly identified and was administered the roommate's medications in error. Resident #54 was sent to the emergency room and was admitted to the intensive care unit. Resident #54 developed [CONDITION(S)] (low blood pressure) & [CONDITION(S)] (low heart rate) which required intravenous (IV) fluids, medication, and continued telemetry (heart) monitoring. This indicated harm. The findings included: Resident #54 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (minimum data set) that was completed for Resident #54 was an OBRA Admission Assessment with an ARD (assessment reference date) of 07/02/2021. Resident #54 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record was reviewed on 09/20/2022 beginning at approximately 8:30 a.m. The progress note section was reviewed and contained the following: 07/02/2021 10:48 AM During AM medication administration, rsd (resident) was administered wrong medications. Rsd VS (vital signs) obtained. 135/79, 72. 98.2, 18, O2 (oxygen) 96% on RA (room air), family in room at time. MD notified of error. Family requested to send rsd to ED (emergency department) (Name of hospital). 911 activated and report called to ED. On 09/20/2022 at approximately 11:30 a.m., the administrator was asked if the facility had investigated the above incident. The administrator presented the facility investigation of the incident at approximately 1:30 p.m. She was asked if the facility had any follow-up information from the hospital after the resident was sent to the ED. She stated she would look. The facility reported incident contained the following: Incident Date: 07/02/2021 Time: 1000 (10:00 a.m.) Describe Injury: Med. (medication) error Narrative of incident and description of injuries: During AM med. Administration rsd received wrong meds. VS: 135/79, 72, 18, 98,.2, O2 98%, family in room and requesting be sent to ED. Report called to ED. Two witness statements were attached to the Incident report. The first statement contained the following: This Nurse called in report to (Name of hospital) in regards to the wrong medications given to the pt (patient). Medications as followed: [MEDICATION(S)] 7.5 mg (antihypertensive) * Vitamin C 1,000 mg (supplement/vitamin) * Calcitrol 0.25 mg (supplement) * [MEDICATION(S)] 6.75 mg (antihypertensive) * [MEDICATION(S)] 0.2 mg (antihypertensive) * Vitamin B-12 1000 mcg (supplement/vitamin) * [MEDICATION(S)] 2.5 mg (anticoagulant) * Famatodine 20 mg (Given to decrease stomach acid) * Senna-S 8.6-50 mg (stool softener) * Sevelamer HCL 800 mg (mineral binding agent) * ED nurse stated that none of these medications were of great concern and there was probably nothing they could do, but they would monitor her BP. *NOTE drug indications in () were not part of the witness statement but added for clarification/information. The second witness statement, written by the nurse who made the medication error contained the following: During AM med. Administration @0920 (9:20 a.m.) rsd was given wrong meds while sitting in the hallway. First day on this hallway with this pt, and I thought she was her roommate .Daughter sitting in doorway & notified that rsd received wrong meds & requested that she be sent to ED for eval (evaluation). Daughter was very understanding & stated to me that it was okay, don't be upset we all make mistakes, and no one is perfect. Rsd with no s/s (signs/symptoms) of distress or c/o (complaints of) discomfort, then obtained VS: 135/79, 72, 98.2, 18, O2 96%. EMS (emergency medical services) arrived @ 0945 (9:45 a.m.) Along with the incident report was a MEDICATION ERROR/OMISSION REPORT which contained the following: Wrong medication .medications administered in error: [MEDICATION(S)] 20 mg, Amolidipine 7.5 mg, Vitamin C 500 mg, Calcitrol 0.25 mg, [MEDICATION(S)] 6.25 mg, [MEDICATION(S)] HCL 0.2 mg, Vitamin B-12 500 mcg (2 tabs), [MEDICATION(S)] 2.5 mg, Famatodine 20 mg, Senna S 8.6-50 mg, Sevelamer HCL 800 mg Physician notified at 0930 (9:30 a.m.) .date 7/2/21. Physician Comments: None, family in room, requested rsd go to hospital . At approximately 1:45 p.m. on 9/20/22, the administrator stated, We actually have the discharge summary from the hospital, I'm not sure why we have it, but here it is. The (hospital) discharge summary contained the following: Physician Discharge Summary admitted : 7/2/2021 discharge date : 7/3/2021 Admission Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Overdose of antihypertensive agent, accidental or unintentional, initial encounter. Indications for Admission: presents to the emergency department via EMS with a chief complaint of feeing shaky. Evidently she had been given another patient's oral medication this morning including [MEDICATION(S)] 20 mg, sevelamer 800 mg, vitamin B-12 1000 mg, [MEDICATION(S)] 2.5 mg, [MEDICATION(S)] 7.5 mg, famotadine 20 mg, vitamin c 1000 mg, [MEDICATION(S)] 6.25 mg, [MEDICATION(S)] 0.2 mg and calcitrol 0.25 mg. In the ER, she was initially normotensive (137/63) with normal sinus rhythm (71) with normal respirations (180) and oxygenation on room air (98%). She was awake and alert, Labs revealed a mild [CONDITION(S)] with H/H (hemoglobin/hematocrit) 10.8/34.3. CMP (Comprehensive Metabolic Profile) was essentially normal. ECG (electrocardiogram) revealed a sinus rhythm (60) with a RBBB (right bundle branch block) which is unchanged from 6/27/21. Poison Control was contacted and advised observation for 6 hours. She was observed on telemetry and developed sinus [CONDITION(S)] into the 40's and [CONDITION(S)] in the systolic 70's. She remained alert and was fairly asymptomatic. She was given IV fluids for pressure support and IV [MEDICATION(S)] 1000 mg. She had improvement in her BP with this therapy although it remained low and her [CONDITION(S)] persisted. After 8 hours of observation in the ER I was asked to admit for observation. Hospital Course: She was admitted to the ICU (intensive care unit) for close observation on telemetry. She received IV fluids for pressure support. She remained in sinus rhythm throughout her stay with some [CONDITION(S)] in the 40's that has recovered to the 50-60's this morning. She developed no other complicating symptoms. Her labs this morning are stable. Her blood pressure had normalized off IV fluids. I discussed her discharge plans with her daughter who plans to care for her at home with other family. I have placed a referral to home health . Entering right after the administrator, the ADON (assistant director of nursing) presented the medication administration policy as requested and stated, The nurse who gave the wrong meds was reeducated after that happened and the pharmacy came in and did med pass audits. She was asked if a plan of correction had been developed for the incident. She responded, No. The facility policy for medication administration contained the following: General Dose Preparation and Medication Administration .Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Facility staff should: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident .During medication administration, facility staff should take all measures required by facility policy and applicable by law, including, but not limited to the following: Identify the resident per facility policy. On 09/20/2022 at approximately 4:00 p.m., the nurse who made the medication error, RN (registered nurse) #3 was interviewed over the phone. She was asked if she remembered the medication error and if so what had happened. She stated, I was an LPN (licensed practical nurse) then .the resident was sitting in the doorway to her room. She and her roommate were new admissions .I gave her, her roommate's meds. She was asked how that had happened. She stated, The residents there don't wear armbands. We have to identify them by the picture in their record .neither one of them had a picture in there. She was asked how she identified residents in the case of no picture. She stated, You hope they don't have dementia and can tell you their name .they have their names on the door and there are typically pictures in there, but with new admits that doesn't always happen. On 09/21/2022 at approximately 9:00 a.m., the administrator and the ADON were asked about the facility policy regarding identification of residents. The administrator stated, We get a picture of them as soon as they arrive and upload it into the system. She was told what RN #3 had stated about there not being a picture in the record at the time of the medication record. She stated, I don't know, it's in there now. She was asked if the resident's wore arm bands. She stated, No. During a meeting with the DON (director of nursing) the ADON, the nurse consultant, and the administrator, on 09/21/2022 at approximately 9:30 a.m., the above information was discussed. The facility staff were informed that based on the investigation the survey team had identified harm to Resident #54. She was given the wrong medications, was sent to the local emergency room , and subsequently admitted to ICU for telemetry monitoring, administered IV medication, and IV fluids. The administrator was asked if any additional information was available the survey team would review it. No further information was presented prior to the exit conference on 09/21/2022. This is a complaint deficiency.

Based on resident interview, staff interview and facility document review, the facility staff failed to consider the views of the resident group and act promptly upon resident concerns/complaints of care and life in the facility for 5 months. Findings include: On 05/11/21 at 10:40 AM, Resident #52 [a resident who attends the group meeting regularly] was interviewed. Resident #52 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #52 stated, that she felt there may be issues with staffing, as the call bell response was slow. Resident #52 stated that when you push the light, you wait and wait and wait. At 11:45 a.m., the administrator stated that a group meeting with the survey team was declined by the resident council president. The resident council meeting minutes were reviewed from October 2020 through April 2021. The council meeting minutes documented concerns from residents regarding slow call bell response in October of 2020, November of 2020, January of 2021, February of 2021, and March 2021. On 05/11/21 at approximately 1:15 PM, Resident #32 [resident council president], who was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32 stated that she didn't think the facility was short on staff, but did voice concerns about slow call bell response times. Some concerns listed in the council minutes were reviewed with Resident #32. The slow call bell response was an ongoing concern. Resident #32 stated that if she rings her call bell and it takes a long time, that she will use her cell phone to call the nurse's station. The resident was asked, when the group meets and has concerns such as this, if there was anyone who follow's up with them to let them know what is being done to address the concern. Resident #32 stated that the AD [activity director] will follow up with her [the resident president] and let her know the concerns have been addressed. The resident stated that if concerns are brought to her, say in the hall by another resident then she, will in turn take those concerns to the AD. Resident #32 was not aware of any official way to track their [group or individual] concerns for progress and resolution to determine that the concerns were actually validated, addressed, and followed up on. On 05/12/21 at 9:30, the administrator stated that the AD was the designated person to help residents with the resident council. At approximately 3:00 p.m., the administrator, ADON (assistant director of nursing), the SW (social worker), QA (quality assurance) nurse, and corporate nurse were made aware of the concerns with the group meeting minutes indicating over 5 months of slow call bell response. The administrator stated that staff will talk to one another in the mornings during their stand up meetings and then stated that there was not an actual process to follow up with concerns voiced by the residents in group. The ADON then stated that she received an email from the AD a while back, which included herself and the administrator regarding call bell response. The ADON stated that an inservice was completed. At approximately 3:30 p.m., the AD was interviewed. The AD stated that she writes down the resident concerns. The AD stated that usually if there is a problem with the kitchen, the kitchen staff will attend or if there is a problem with laundry, the laundry department will attend and try to resolve those issues directly. The AD also stated that she will communicate to the administrative staff via email regarding some concerns. The AD was unaware of any type of concern tracking that the administrative staff may have or use that would help to determine if concerns were being followed and/or tracked and what types of things that may have been put in place to ensure that the concerns were being addressed. On 05/12/21 at 5:00 p.m., the administrator, ADON (assistant director of nursing), the SW (social worker), QA (quality assurance) nurse, and corporate nurse were again made aware that concerns voiced by the residents were not being addressed. The administrator asked about the inservice. The administrator was made aware that the resident's had voiced concerns with slow call bell response times for 5 months and an inservice was completed in April. The inservice sheets that were presented were dated 04/20/21, 04/26/21, and 04/28/21 and documented for staff to answer call bells timely and that call bells should be in reach, and that ideally the call lights would be answered with in 3 to 5 minutes. No further information and/or documentation was presented prior to the exit conference on 05/12/21.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (minimum data set) was completed for Resident #2 regarding a Level II PASRR [preadmission screening and resident review]. Findings include: Resident #2 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent full MDS was a five day admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 3, indicating the resident had severe impairment in daily decision making skills. The resident was also assessed as having [CONDITION(S)] in Section I. The resident was assessed in Section A. A1500. Preadmission Screening and Resident Review (PASRR) as no, indicating the resident did not have a serious mental illness. In Section A. A1510. Level II Preadmission Screening and Resident Review (PASRR) the resident was not assessed, this area was blank on the MDS. This section was not completed and did not identify that Resident #2 had a serious mental illness. Resident #2's clinical record did not include any information for a Level I or Level II PASRR. On 05/12/21 10:06 AM, the SW [social worker] was interviewed regarding the above information. According to the SW this resident was admitted on [DATE] and was referred for a Level II PASRR prior to admission, which did not recommend outside psychiatric services. The SW was asked to present the information. On 05/12/21 01:10 PM, the SW presented the information that was in the resident's paper chart. Resident #2 had a Level I and a Level II completed prior to entry to the facility. The resident did not require any resources outside of the long term care facility. The SW was not sure why this was triggered. The SW was asked who completes the admission MDS for residents and where would information regarding PASRR come from. The SW stated that would be MDS and the information is usually kept by the admissions department as this is done prior to admission. The MDS Coordinator [MDSC] was interviewed on 05/12/21 at approximately 2:30 p.m. The MDSC looked up the MDS for Resident #2 and stated that the information in Section A1500. was incorrect and that section A1510. should have been completed. The MDSC stated that the person who completed this MDS is no longer with the company and further stated that the information regarding PASRR is typically obtained from admissions and/or the business office because that information is obtained prior to admission and passed on to the MDS department for input into the resident's MDS. The MDSC also stated that staff would also ask to get that information from the SW or from the admission office to complete the MDS accurately. The MDSC stated that she could not speak to how the previous MDS person's process was or how she may have obtained information for MDS accuracy. No further information and/or documetnation was presented prior to the exit conference on 05/12/21.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure two of 17 residents were assessed and provided appropriate care and treatment/services for the identification of complications related to the prolonged use of an indwelling catheter. 1. Facility staff failed to assess, treat, and provide appropriate interventions related to the prolonged use of an indwelling catheter for Resident #29. Resident #29 was identified by the urologist as having urethral erosion from the prolonged use of an indwelling catheter and recommended the resident undergo a procedure for a suprapubic catheter. There was no documentation in the clinical record that the recommendations had been discussed with the responsible party, nor was there any evidence of the facility's ongoing assessment of the area. Resident #29 had severe urethral trauma which was identified as harm. 2. Facility staff failed to assess and provide appropriate services to identify complications related to the use of an indwelling catheter. Findings were: 1. Resident #29 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: [MEDICAL CONDITIONS], dysphagia, Type II diabetes mellitus, [MEDICAL CONDITIONS], and hypertension. The quarterly MDS (minimum data set) with an ARD (assessment reference date) of 01/07/2019, assessed Resident #29 as severely impaired in his cognitive status with a summary score of 06. On 02/12/2019 at approximately 12:15 p.m., Resident #29 was observed sitting in his wheelchair at a table in the dining room. His catheter bag was attached to the top of his wheelchair back, at shoulder level. The catheter tubing was observed coming out of his left pants leg, under the wheelchair, and up the back of the chair to the drainage bag. There was no urine in the tubing. At approximately 3:45 p.m., Resident #29 was observed sitting in his wheelchair in the hallway. His catheter bag was in the same position. The tubing under the chair was filled with bright red fluid. A CNA (certified nursing assistant) came down the hallway and invited Resident #29 to an activity in the dining room. She wheeled him down the hall, she did not reposition the bag. The DON (director of nursing) was in her office with the ADON (assistant director of nursing) and the MDS nurse, LPN (licensed practical nurse) #2. A copy of the facility policy regarding catheters was requested from DON. She was asked about the placement of catheter bags. She stated, Below the level of the bladder. The observation in the hallway was discussed. The ADON and LPN #2 left the office At approximately 4:00 p.m., this surveyor went to the dining room; Resident #29 was no longer in the activity. Resident #29 had been taken to his room by the ADON and LPN #2. The DON came down the hall and entered the room with this surveyor. Resident #29 was lying on his bed, his brief was partially off. The catheter tubing had been emptied. The catheter bag was hanging on the top side rail, at mid chest level. Resident #29 was not circumcised, the foreskin of his penis was retracted by LPN #2. She stated, He has a split here on the underside of his penis. Resident #29's penis was split from the head down shaft; the catheter was not inserted in his penis at all but directly into the scrotal area. There was fresh blood around head of penis. The catheter tubing was not anchored. The ADON was asked why the catheter was not anchored. She stated, The doctor doesn't want his catheter anchored .we have an order not to the family didn't want a suprapubic catheter but they have now agreed. The clinical record was reviewed, and there were no orders to not anchor the Foley catheter. The skin assessments were reviewed. There was no mention on the skin assessments of Resident #29's penis. The DON was asked if there was any documentation regarding the family's refusal of the suprapubic catheter or where anyone had spoken to them. She stated, I'll see what I can find. At 4:30 p.m., the wound nurse went to Resident #29's room to measure the open area on his penis. She was asked if she had measured the area in the past. She stated, No, this is the first time I have looked at him. The area measured, 5.5 cm long and 1 cm wide. The wound nurse stated, I've never seen anything like this .I'm not sure what to do. The catheter tubing was still not anchored. The tubing went out of his brief, down his pants leg, and up to the catheter bag, still hanging at mid chest level. The wound nurse was asked if there was tension on the tubing. She stated, Yes, and moved the catheter bag down on the bed frame. Resident #29 stated, That's enough, that's enough, it's sore. The facility policy Catheter Care, Urinary was reviewed and contained the following information: The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site if resident will allow and is able to tolerate .The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color .clarity .and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. On 02/13/2019 the clinical record was reviewed for further information. The POS (physician order [REDACTED]. The nurse's notes were reviewed from 08/01/2018 - 02/13/2019. There was no documentation as outlined in the facility policy regarding assessments, problems with the catheter site, interventions, etc., during any of the catheter changes or when catheter care was provided each shift. The urology notes were reviewed and contained the following: 01/04/2018 Recurrent UTI's, Chronic [MEDICAL CONDITION], Acquired hypospadial urethral erosion .recommendations: I will discuss with (physician name) re: SPT (suprapubic catheter) vs continued Foley . 08/13/2018 Chronic [MEDICAL CONDITION] .urethral erosion. Recommendations: Change Foley catheter every 4 weeks, *Flush Foley at least twice a week, strongly consider suprapubic catheter if patient can be medically cleared. There was no documentation in the clinical record from either the nursing staff of the primary physician that the need for a suprapubic catheter was discussed with the family. On 02/13/2019 at approximately 2:00 p.m., the DON and the wound nurse came to the conference room to discuss Resident #29. The DON stated, I can't find very much in the record .here's a note from (MONTH) (YEAR), one form (MONTH) (YEAR) and one from (MONTH) (YEAR) that's it. The notes contained the following: 04/26/2017 While looking at RSD (resident) penis for cath care, I observed some tearing and a small mount of blood on the underside of the penis at the urethral opening. I contacted MD .he ordered a consult to urology . 11/3/2017 Resident went to ER .due to pulling at Foley. Resident transferred himself to the bathroom without assistance .Resident states . he accidentally sat on his cath. The head of resident's penis is torn and resident is having some bloody drainage . The DON was asked if there was any follow-up documentation or measurements of the areas described in the notes. She stated, No, this has been a slow ongoing thing with him .when he came back from the urologist in (MONTH) (2018) the nurse wrote an order to change the catheter every 4 weeks, because we were changing it weekly per the family's request, she wrote to consider suprapubic catheter placement after he was medically cleared .I asked her if she discussed that with the family and she doesn't remember .there aren't any notes in the record from (name of Resident #29's physician) about it. The DON was asked since it was a slow ongoing thing wouldn't that be all the more reason to be documenting the measurements/appearance of the area in the clinical record. She nodded her head, indicating Yes. The wound nurse stated, I called his sister last night .he (Resident #29) was trying to get out of the bed, kicking off his covers, pulling at his catheter .she said that she knew he had pulled it out twice in the past .she said he just doesn't realize he is hurting himself . The wound nurse stated, He does pull at his catheter sometimes. The DON was asked if there was any place in the record other than on the TAR (treatment administration record) where nurse's documented catheter care or changing of the catheter. She stated, No. She was asked where the documentation outlined in the facility policy regarding care of the Foley catheter would be documented. She stated, It isn't. The care plan was reviewed, the focus area: ADL/Incontinence/Skin .Foley cath in place d/t (due to) [MEDICAL CONDITION]/[MEDICAL CONDITION], had the following interventions: Provide Foley cath care. Keep cath bag below level of bladder and empty bag as needed throughout the shift. Do not allow cath bag to touch the floor 1/29: Urethral tear has worsened . An additional focus area: Catheter/UTI (Urinary Tract Infection) risk .has urethral tear from Foley cath (no date this was added); 1/29: Urethral tear from Foley has worsened. Urology consult for suprapubic cath scheduled .Interventions included: Change Foley per current MD order; Monitor for s/sx (signs and symptoms) of UTI ., change catheter drainage bag weekly; cue/remind resident as needed of importance of keeping drainage bag below bladder to decrease the risk of infection; Monitor Foley insertion site for s/sx of trauma/infection, i.e. redness, purulent drainage, pain, etc and report to nurse/MD; Provide Foley cath care. Keep cath bag below level of bladder and empty as needed throughout the shift. Do not allow cath bag to touch floor; Assist resident with proper placement of catheter drainage bag below level of bladder; Flush Foley per current MD order. The DON and the wound nurse were informed that there were no interventions on the care plan, nor had there been any documentation observed in the clinical record regarding Resident #29 pulling at his Foley catheter. On 02/14/2019 at approximately 8:50 a.m., the Corporate Medical Director came to the conference room to speak with the survey team. He stated that he had examined Resident #29 for the first time the previous evening. He stated that penile/urethral erosion was very common in elderly due to long term catheter usage. He stated that in his opinion, the facility's lack of documentation and assessment was not the issue, but the failure was that the urologist had not provided appropriate interventions and that the facility needed to get a second opinion from another urologist. He stated that he did not think the facility had caused the resident harm and what he saw was not an acute problem. The Corporate Medical Director was referred to a nurse's note written on 02/10/2019 which contained information that Resident #29 had >100,000 mixed bacterial flora in his urinalysis and the culture and sensitivity was pending. He was asked if he felt the placement of the catheter bag, well above the level of the bladder would contribute to a urinary tract infection, He stated, No, the contributing factor to his UTI's is the placement of the catheter, not the position of the bag. The Corporate Medical Director's was reviewed at approximately 9:45 a.m. The note contained the following: This is an [AGE] year old patient that is a long term resident of the facility that has had a Foley catheter for about 2 years and has had multiple follow-ups with the urologist. On assessment, the patient has no acute pathology/swelling/evidence of trauma/evidence of Foley catheter irritation or allergy to the tubing of the Foley catheter the presentation of the patient's penis/urethral meatus on todays (sic) visit is similar in appearance that was present during the urological visit and furthermore, the presence of the urethral meatus separation is a common problem in the geriatric population from long standing Foley cath use . At 10:10 a.m., the urologist that had examined Resident #29 was contacted via telephone. A message was left with his office staff asking him to call this surveyor regarding Resident #29. The urologist did not return the call. During and end of the day meeting on 02/14/2019 at approximately 12:15 p.m., with the DON and the administrator the above information was discussed. The DON was asked if the primary care physician had submitted any information regarding the progression of Resident #29's urethral erosion. She stated, Not yet. The DON and the administrator were informed that the facility's failure to assess and document changes in the erosion of Resident #29's penis were identified as harm by the survey team. At approximately 12:45 p.m., the DON presented a note that had been faxed to the facility from the primary care physician regarding Resident #29. Information included: Asked by staff to comment on (name of Resident #29) chronic Foley catheter. He was last seen by urology around (MONTH) (YEAR) and option for suprapubic catheter was raised. Apparently, his sister was not in favor of that because of her fear of the risks of surgery and he had been through a lot of issues with his pacemaker right before that. Last fall I was encouraging his sister to move his care to a palliative only direction (Hospice, for example) but she was not in favor of that at the time. He has frequent UTIs and intermittent pain in that area (usually with UTIs). As all patients with Foley catheters in that long, he has erosion and enlargement of his urethra now The DON was asked if the primary care physician had discussed the suprapubic catheter with the family in August. She stated, I don't know, it's not in the note. No further information was obtained prior to the exit conference on 02/14/019. 2. Resident #12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) 10/01/2018. Resident #12 was assessed as severely impaired in his cognitive status with a total cognitive score of four out of 15. On 02/12/2019 at 9:49 a.m., Resident #12 was observed sitting in his wheelchair (w/c) at the end of a hallway with his eyes closed. His Foley catheter bag was observed hanging from the handles on the back of his wheelchair. The level of his drainage bag was above his waist. Urine observed in the tubing was cloudy, yellow with white sediment. Resident #12 was observed at 3:44 p.m. in activities with his catheter drainage bag hanging from the handles on the back of his wheelchair. The DON (director of nursing) was interviewed at 3:50 p.m. regarding placement of Resident #12's drainage bag. The DON stated, I don't know why they are doing that now. We were making sure the bags were below the chair, but not dragging the floor. Those bags (referring to privacy bags) have straps long enough to hang the drainage bags low. On 02/13/2019 at 8:00 a.m. LPN #1 (licensed practical nurse), wound care nurse, and this surveyor assessed Resident #12's penis and Foley catheter. Resident #12's urinary meatus was split from the opening of his penis to the start of his penile shaft. Catheter tubing was secured to his right thigh and the drainage bag was hanging on the right side of the bed, below the bladder. Resident #12 denied pain from the catheter. Resident #12's clinical record was reviewed on 02/13/2019 at approximately 8:30 a.m. During this review urology visit notes included the following documentation: 03/08/2018 - .he has had foley several months and has penile erosion. Urethral erosion. Foley in several months, with erosion ventrally up 50% of shaft. Consideration for sp (suprapubic) tube is made . 06/21/2018 - .[MEDICAL CONDITION] & Penile Erosion .Significant erosion .I do not feel SP tube is indicated now . 09/27/2018 - .No change in penile erosion . 12/13/2018 - .Penile erosion stable. Cont (continue) monthly tube change. Continue to affix to leg. Watch device & ensure tube/foley is not kinked . 01/17/2019 - .He had gross hematuria and went to ER (emergency room ) .Change Foley per routine. We might consider imaging if this recurs. Subsequent review of physician progress notes [REDACTED].#12's penile erosion or mention of any of his urology visits. The current POS (physician order [REDACTED].Order Date: 11/21/18 Foley Cath Care Every Shift .Change Foley Bag Weekly .Change Foley Catheter 16FR 30ML Balloon as needed .Ensure Foley leg strap/cath secure in place to prevent tension on Foley .Order Date: 02/12/19 Change Foley Catheter 16FR 30ML balloon Q (every) month . Resident #12's CCP (comprehensive care plan) included: ADL (activities of daily living)/Incontinence/Skin .Monitor skin integrity during personal care and notify nurse/MD of any impairements (sic) .Provide foley cath care every shift. Ensure foley leg strap is on with cath secured to prevent tension on foley. Empty cath bag as neede. (sic) Change cath bag weekly. Ensure cath bag is placed below level of bladder. Do not allow cath bag to touch floor. Change foley catheter monthly and as needed per current MD order . Resident #12's son was interviewed via phone on 02/13/2019 at 11:24 a.m. The son stated, We have had issues since he had the catheter placed. He was retaining urine and unable to empty his bladder. He has had several infections and problems with getting the catheter replaced. He sees a urologist that changes his catheter. I was not aware that he has a split from the catheter. The urologist mentioned a suprapubic catheter once when he first started seeing them, but not recently. The doctor really doesn't like them. The DON and LPN #1 were interviewed on 02/13/2019 at 3:20 p.m. regarding Resident #12's penile erosion. LPN #1 stated, I do skin checks, but I don't always look at penises, so I guess that's on me. I did not know his penis was split until yesterday. No, I have not measured the area. The DON stated, I didn't know either. We identified a problem with assessments and documentation on the first of (MONTH) and have been inservicing the staff. LPN #1 came to the conference room at approximately 3:45 p.m. and stated the eroded area (split) area on Resident #12's penis measured 3cm x 0.5cm (centimeters). The only mention of Resident #12's penile erosion in nursing notes was in a note dated 02/01/2019 at 9:45 p.m. and a note dated 02/09/2019 at 1:28 a.m., both written by the same LPN. Both notes stated, .Foley cath intact and patent draining clear yellow urine without difficulty .Penile head remains split . These notes had corresponding skin assessments. No other skin assessments were located in the record. On 02/14/2019 at approximately 8:30 a.m. the DON and Corporate Medical Director approached the conference room and asked to speak to the survey team. He stated he had assessed Resident #12 and had written a note. He concluded with stating, His penile erosion is a chronic problem without current acute symptoms. This is very common in elderly males with long term catheter use. He has been seen by the urologist several times and also has been to the hospital for catheter issues. I cannot argue that the documentation sucks and that another urologist should have been consulted, but I do not feel the facility has caused harm. The Corporate Medical Director's clinical note dated 02/13/2019 included: .long term resident of the facility that has had a foley catheter for over 2 years and has had multiple follow ups with the urologist. On assessment the patient has no acute pathology/swelling/evidence of trauma/evidence of foley catheter irritation or allergy to the tubing of the foley catheter. He was last seen by the urologist on 03/08/2018, 12/12/18, and 01/17/2019. The current status of the urethral meatus separation had been present on these last several visits with no urological intervention recommendation except for recommendation that the patients foley not get kinked. The presentation of the patients Penis/urethral meatus on todays visit is the similar appearance that was present during the urological visit and furthermore, the presence of the urethral meatus separation is a common problem in the geriatric population from long standing foley cath use . The Corporate Medical Director stated this was the only time he had ever seen and assessed Resident #12. Several attempts were made on 02/14/2019 at 10:30 a.m. to contact Resident #12's urologist. The phone always rang busy. Facility policy, Catheter Care, Urinary included the following documentation: Maintaining Unobstructed Urine Flow .3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .Changing Catheters .14. Assess the urethral meatus .18. Secure catheter utilizing a leg band. 19. Check drainage tubing and bag to insure (sic) that the catheter is draining properly .Documentation - The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine . The Administrator was informed of the above findings during a meeting with the survey team on 02/14/2019 at 12:10 p.m. No further information was received by the survey team prior to the exit conference on 02/14/2019.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, facility staff failed to prevent one of 10 residents from two falls within 38 hours, both resulting in harm, Resident #109. Facility staff failed to ensure Resident #109's safety, resulting in two falls within 38 hours, both resulting in fractures. Findings included: Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a 14-day assessment with an ARD (assessment reference date) of 10/25/17. Resident #109 was assessed as moderately impaired in her cognitive status with a total cognitive score of nine out of 15. Resident #109's EMR (electronic medical record) was reviewed on 04/03/18 at 2:05 p.m. During this review a Fall Risk assessment dated [DATE] showed a total fall score of 15. 10 or higher on the scale equaled high risk for falls. Section G - Functional Status on the MDS with an ARD of 10/25/17 included Resident #109 needed extensive assistance of two or more person physical assist with bed mobility and transfers; required extensive assistance of one person physical assist with locomotion on and off the unit; ambulation in her room or corridor was coded as did not occur. The CCP (comprehensive care plan) for Resident #109 included the following: .Problem Onset: 10/13/2017 FALL RISK Resident is at risk for falls r/t (related to) impaired cognitive status, left meniscus tear, left knee pain, weakness, and ataxic gait. Bed and w/c (wheelchair) alarms in place. Goal & Target DATE: Resident will not experience injury from a fall requiring ED (emergency department)/hospitalization through next review. Approaches: Keep bed in lowest position with wheels locked .Keep call light within reach and encourage resident to call for assistance as needed .Ensure resident is wearing proper footwear when out of bed .Monitor for changes in health condition, ie increased confusion .Assist resident as needed with ADLs, transfers, and mobility .Ensure bed and w/c alarms are on and working properly at all times . Both falls, 11/5/17 and 11/7/17, were listed on the CCP, but no other interventions were added to the care plan. Nursing Progress Notes included the following documentation: 11/5/17 10:29 a.m. - RSD (resident) found in the bed room floor with bed alarm sounding. no (sic) complaints of pain or discomfort . 11/5/17 11:12 a.m. - rsd (sic) sent to ED (emergency department) per RP (responsible party) request d/t (due to) left wrist pain . 11/5/17 2:40 p.m. - .rsd (sic) is 1-person assist with ADL (activities of daily living) transfers .Scheduled pain meds held per family. She returned to the facility from (Hospital Initials) at 1400 (2:00 p.m.). She is s/p (status [REDACTED]. 11/5/17 10:32 p.m. - .Resident is 1-2 person for ADLs and transfers. Resident is alert to self only and is confused. Resident is also post fall. Resident fell on morning shift and has a left metacarpal fx (fracture). Resident has complained of pain and discomfort during the shift .Resident pulled the tempory (sic) cast off of her arm . 11/6/17 4:14 a.m. - .Resident S/P fall and ER visit on 11/5, left arm soft splint cast intact at this time. Resident agitated at beginning (sic) of shift, .attempted to self transfer several times, resident assisted up to w/c (wheelchair) and placed at nurses station for supervision .Safety reminders provided, however due to residents dementia unable to show understanding .Safety measures in place . 11/6/17 2:08 p.m. - .Resident is alert with confusion .S/P fall and ER visit with L (left) metacarple (sic) fx. Soft splint cast to LUE (left upper extremity) is C/D/I (clean/dry/intact) .Requires 1 with ADLs/transfers . 11/7/17 4:12 a.m. - Around 2330 (11:30 p.m.) this nurse heard resident's bed alarm sounding. This nurse went into pt's room, pt was trying in get up from bed. (sic) Attempted to redirect pt about going back to bed since it was bedtime. This nurse was not successful. CNA (certified nursing assistant) was asked to help redirect pt. Resident was gotten up in w/c and positioned at nurses' station with staff. Resident was very confused and yelling with her nurse, stating she was in a prison. fell ow nurse asked if pt was in pain and tried to assess pt, resident became more aggressive and combative. Resident did eventually calm down. At about 2430 (12:30 a.m.), this nurse was in nurses' station checking charts when this nurse noted that the pt was trying to stand up from w/c. This nurse asking pt to sit back down (sic), resident did sit was down in chair (sic). Resident quickly then jumped up from w/c and stepped 2 steps to her left with her legs twisted. At that time, this nurse and 2 CNA tried to get around the nurses' station to resident but was unsuccessful. Resident had fallen face first to floor infront (sic) of pantry door. Resident's alarm was sounding once was on the ground (sic). Resident has (sic) laying on her right side and blood was coming from the top of her nose. Both CNAs was with resident while this nurse went to get the nurse for the pt. 11/7/17 7:38 a.m. - Resident on floor from fall lying on her back. evaluated (sic) residents visible injuries. resident (sic) had abrasion on her nose that was bleeding, subsided with pressure. skin (sic) tear on lf (left) elbow bleeding applied dry dressing. abrasion (sic) to left knee and bruising appearing. resident (sic) has right arm partially under her, unable to move arm without pain .resident very vocal and confused .911 called and resident transferred to (Hospital Name) ED . The Resident Incident Report dated 11/5/17 at 10:00 a.m. including the following: .Narrative of incident and description of injuries: RSD found in floor with bed alarm sounding .No injuries. Witness statement of Other #1 included: Heard a cry for help. Went to room [ROOM NUMBER] found patient on floor - called for nurse and CNAs - they came and helped her. (sic) Witness statement of LPN #3 (licensed practical nurse) included: After speaking will (sic) staff working on 11/5/17 when (Name) Resident #109 fell , her daughter had been here visiting, when she left (Name) Resident #109 tried to get OOB (out of bed) to go change her shirt because she had spilled something on it and wanted to change her shirt. Her call bell was within reach but she did not ring. Light was off when she was found. She was found @ (at) the bedside, said she was trying to get up to go change her shirt. Her bed alarm was sounding when nurse entered bedroom. A housekeeper alerted her that (Name) Resident #109 was @ her bedside on the floor. (Name) LPN #3 said @ first she had no complaints but shortly after started complaining of her hand hurting. Family wanted her sent to ER. She was sent and returned with a broken finger . This surveyor interviewed Other #1 on 4/4/18 at 9:05 a.m. regarding Resident #109's fall on 11/05/17. Other #1 stated, She (Resident #109) had been in her w/c. I had stopped in a few minutes earlier and spoke to her and her roommate like I always do. I was in room [ROOM NUMBER] cleaning, when I heard someone holler, Help, we need help in here. I ran to the room and she (Resident #109) was already on the floor. I ran and got the nurse. There was a low beeping (muffled), sounded like the batteries were going dead. I didn't know at the time it was an alarm. No I did not hear the beeping in the other room. I just heard someone yelling for Help. Documentation in the ER note dated 11/5/17 included: .Arrived per EMS (emergency medical services) with c/o of a fall and patient with hematoma to the left hand and c/o of left arm pain from the shoulder to the hand .bruising noted to the top of the left hand .Nondisplaced fracture of base of second metacarpal bone, left hand, initial encounter for closed fracture. The Resident Incident Report dated 11/7/17 at 12:30 a.m. included the following: Narrative of incident and description of injuries: Resident in w/c with alarm at nurses station. Resident stood up nurse ask her to sit down before she and CNAs could reach her she fell face forward to floor. (sic) Witness statement of CNA #2 included: I came in to work at 10pm. (Name) Resident #109 was in bed awake and moving around. Her bed alarm was going off. I got her to lay back down (Name) Resident #109 laid back down. She laid there for about 30 mins. Then she was setting back up in her bed. Got her to lay back down around 11:30pm. (Name) Resident #109 would not stay in bed and the aide (Name) got her up and put her in her wheelchair with her alarm on. While (Name) Resident #109 was setting at the nurse desk. She was very confused and very combative. At around 12:30 am on Tue [DATE] (Name) Resident #109 went to stand up and lost her balance and fell . I was running trying to get to her, but I could not get to her fast enough . Witness statement of LPN #2 included: I was in another residents room giving prn (as needed) pain med. CNA called me to come to nurses station. (Name) Resident #109 was in the floor on her back 2 CNA's and nurse were present. (sic) I assessed injuries .as we were sending her to ED . Witness statement of CNA #3 included: (Name) Resident #109 was in bed attempted to get up. Nurse (Name) LPN #1 asked me to assist her, so I went into the room she was trying to get her legs out of bed. (sic) I reminded her not to get up or she would fall. She wanted to get up. I then got her up put her in her wheelchair turned her alarm on and sit her in front of the nurses station the time was around 11:30 (sic) I was sitting around the nurses station on my 15 min break I was on the other side next to the med room. (sic) I heard her alarm go off I looked up and she was going down I knew it was late to get to her as she fell her head hit the floor (Name) LPN #2 was right there as soon as it happened along with (Name) CNA #2. (sic) That was 12:30 . Witness statement for LPN #1 included: While in was in (sic) med room I heard (Name) Resident #109 alarm going off. She was trying to get up. I tried to tell her that it was bedtime but she continued to try to get up. I asked (Name) CNA #3 if she could get her to go back to bed. (Name) CNA #3 got her up since she said that she wanted up. (Name) Resident #109 was brought up to the desk where we all was .She was agitated. (Name) Resident #109 started screaming that we had locked her up & (and) that she was a prisoner .She went to stand up from her w/c without assistance. I asked her if she could sit back down and she did. Suddenly then she jumped up and stepped 2 steps to her left with her legs crossed. Me (LPN #1) & (Name) CNA #3 and (Name) CNA #2 got her as quick as we could but I was within the nurse station . This surveyor interviewed CNA #2 on 4/4/18 at 2:40 p.m. regarding Resident #109's fall on 11/7/17. CNA #2 stated, I came on at 10:00 and got report from the off-going shift. Around 10-10:30, she was in bed. Around 11-11:30, she was trying to get up, kept sitting up making her alarm go off. (Name) CNA #3, the other girl working with me that night got her up and brought her to the nurse's desk in her w/c. She was agitated and restless. She was in her w/c sitting near the pantry door. I was sitting close to the clean utility room charting my ADL's. I had my chair positioned so I could see down the blue hall and the pink hall. I could see her from the waist up. I was able to see her because I am tall, not like the rest of them. I noticed she was leaning over in her w/c. I stood up to see and she stood up, took a couple of steps and fell on her face. I ran around the nurse's desk, but couldn't reach her fast enough. (Name) CNA #3 the other CNA was near the doctor's office and she ran towards her too, but couldn't reach her either. Normally we sit close to them, like in arms reach. I don't know why we weren't closer to her since she was so agitated and restless. That is a good question. LPN #1 was interviewed via phone on 4/4/18 at 3:20 p.m. LPN #1 stated, I was inside the nurse's station pulling charts or doing something with the charts. (Name) Resident #109 was sitting near the pantry in her w/c. I bent down to do something with a chart and when I stood up she was standing up. Before I could get out of the nurse's station and around to her, she fell . There were two aides outside of the nurse's station also. Normally someone is within arms reach. The two aides were outside the nurse's station. LPN #2 was interviewed via phone on 4/4/18 at 3:25 p.m. LPN #2 stated, I remember her being in the floor. I was in another resident's room giving a treatment when the aide came and got me. There was another aide and nurse with her. I knew he arm was broken because of how it was laying. We called 911. I feel they did the best they could with the 1:1. I remember she was extremely restless, like a jack in the box, up/down, up/down. She didn't want anyone touching her. She wanted her daughter and to go home. I probably would have called the daughters if she would have stayed that way, but I was giving nightly meds. She fell before I could call. I think they did the best they could. CNA #3 was interviewed via phone on 4/4/18 at 3:40 p.m. CNA #3 stated, I came into work at 10:00. She was restless, kept trying to get up, so we got her up in her w/c and brought her to the nurse's station because we were afraid she was going to fall. I was on the opposite side of the desk. The nurse kept telling her to sit down. I did not see the actual fall, but I heard it. I heard the nurse say, sit back down and then I heard her hit the floor. My back must have been turned at the time. I guess we weren't watching her at that moment. I don't remember if the alarm was going off or not. I just remember hearing her hit the floor. The nursing station was in the shape of a diamond, completely enclosed with a door between the North and West points of the diamond. The counters of the nurse's station were approximately four feet tall all the way around. Resident #109 was sitting in her w/c between the East and South point of the diamond. CNA #3 was near the West point of the diamond. CNA #2 was sitting between the North and West points of the diamond. LPN #1 was inside of the nurse's station with the door closed. As documented in the above interview with CNA #3, She was restless, kept trying to get up, so we got her up in her w/c and brought her to the nurse's station because we were afraid she was going to fall. The resident was not placed near anyone that could have maybe prevented or cushioned her fall. She was brought to the nurse's station in her w/c, left to sit alone with no one in close proximity to discourage her from getting up or prevent her from falling. Per the interview with CNA #3, My back must have been turned at the time. I guess we weren't watching her at that moment. Per the staff interview no one was watching the resident at the time of her fall. Documentation in the ER note dated 11/7/17 included: .presents to ED for complaint of right humerus pain and a laceration to the bridge of her nose after falling out of her wheelchair .This is her second fall in 2 days. She suffered a hand fx (fracture) on the first fall .This is the pts second fall in 36 hours. She was evaluated for the first fall and suffered metacarpal fx of the left hand. Today she suffered displaced fx of the right humeral neck and an abrasion/hematoma to the nose . The DON (director of nursing) was interviewed at 4:00 p.m. during a meeting with the survey team regarding Resident #109's fall on 11/7/17. The DON stated, I don't know what they were thinking. I guess they thought they would be able to get to her in time. No further information was received by the survey team prior to the exit conference on 4/4/18.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, facility staff failed to prevent one of 10 residents from two falls within 38 hours, both resulting in harm, Resident #109. Facility staff failed to ensure Resident #109's safety, resulting in two falls within 38 hours, both resulting in fractures. Findings included: Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a 14-day assessment with an ARD (assessment reference date) of 10/25/17. Resident #109 was assessed as moderately impaired in her cognitive status with a total cognitive score of nine out of 15. Resident #109's EMR (electronic medical record) was reviewed on 04/03/18 at 2:05 p.m. During this review a Fall Risk assessment dated [DATE] showed a total fall score of 15. 10 or higher on the scale equaled high risk for falls. Section G - Functional Status on the MDS with an ARD of 10/25/17 included Resident #109 needed extensive assistance of two or more person physical assist with bed mobility and transfers; required extensive assistance of one person physical assist with locomotion on and off the unit; ambulation in her room or corridor was coded as did not occur. The CCP (comprehensive care plan) for Resident #109 included the following: .Problem Onset: 10/13/2017 FALL RISK Resident is at risk for falls r/t (related to) impaired cognitive status, left meniscus tear, left knee pain, weakness, and ataxic gait. Bed and w/c (wheelchair) alarms in place. Goal & Target DATE: Resident will not experience injury from a fall requiring ED (emergency department)/hospitalization through next review. Approaches: Keep bed in lowest position with wheels locked .Keep call light within reach and encourage resident to call for assistance as needed .Ensure resident is wearing proper footwear when out of bed .Monitor for changes in health condition, ie increased confusion .Assist resident as needed with ADLs, transfers, and mobility .Ensure bed and w/c alarms are on and working properly at all times . Both falls, 11/5/17 and 11/7/17, were listed on the CCP, but no other interventions were added to the care plan. Nursing Progress Notes included the following documentation: 11/5/17 10:29 a.m. - RSD (resident) found in the bed room floor with bed alarm sounding. no (sic) complaints of pain or discomfort . 11/5/17 11:12 a.m. - rsd (sic) sent to ED (emergency department) per RP (responsible party) request d/t (due to) left wrist pain . 11/5/17 2:40 p.m. - .rsd (sic) is 1-person assist with ADL (activities of daily living) transfers .Scheduled pain meds held per family. She returned to the facility from (Hospital Initials) at 1400 (2:00 p.m.). She is s/p (status [REDACTED]. 11/5/17 10:32 p.m. - .Resident is 1-2 person for ADLs and transfers. Resident is alert to self only and is confused. Resident is also post fall. Resident fell on morning shift and has a left metacarpal fx (fracture). Resident has complained of pain and discomfort during the shift .Resident pulled the tempory (sic) cast off of her arm . 11/6/17 4:14 a.m. - .Resident S/P fall and ER visit on 11/5, left arm soft splint cast intact at this time. Resident agitated at beginning (sic) of shift, .attempted to self transfer several times, resident assisted up to w/c (wheelchair) and placed at nurses station for supervision .Safety reminders provided, however due to residents dementia unable to show understanding .Safety measures in place . 11/6/17 2:08 p.m. - .Resident is alert with confusion .S/P fall and ER visit with L (left) metacarple (sic) fx. Soft splint cast to LUE (left upper extremity) is C/D/I (clean/dry/intact) .Requires 1 with ADLs/transfers . 11/7/17 4:12 a.m. - Around 2330 (11:30 p.m.) this nurse heard resident's bed alarm sounding. This nurse went into pt's room, pt was trying in get up from bed. (sic) Attempted to redirect pt about going back to bed since it was bedtime. This nurse was not successful. CNA (certified nursing assistant) was asked to help redirect pt. Resident was gotten up in w/c and positioned at nurses' station with staff. Resident was very confused and yelling with her nurse, stating she was in a prison. fell ow nurse asked if pt was in pain and tried to assess pt, resident became more aggressive and combative. Resident did eventually calm down. At about 2430 (12:30 a.m.), this nurse was in nurses' station checking charts when this nurse noted that the pt was trying to stand up from w/c. This nurse asking pt to sit back down (sic), resident did sit was down in chair (sic). Resident quickly then jumped up from w/c and stepped 2 steps to her left with her legs twisted. At that time, this nurse and 2 CNA tried to get around the nurses' station to resident but was unsuccessful. Resident had fallen face first to floor infront (sic) of pantry door. Resident's alarm was sounding once was on the ground (sic). Resident has (sic) laying on her right side and blood was coming from the top of her nose. Both CNAs was with resident while this nurse went to get the nurse for the pt. 11/7/17 7:38 a.m. - Resident on floor from fall lying on her back. evaluated (sic) residents visible injuries. resident (sic) had abrasion on her nose that was bleeding, subsided with pressure. skin (sic) tear on lf (left) elbow bleeding applied dry dressing. abrasion (sic) to left knee and bruising appearing. resident (sic) has right arm partially under her, unable to move arm without pain .resident very vocal and confused .911 called and resident transferred to (Hospital Name) ED . The Resident Incident Report dated 11/5/17 at 10:00 a.m. including the following: .Narrative of incident and description of injuries: RSD found in floor with bed alarm sounding .No injuries. Witness statement of Other #1 included: Heard a cry for help. Went to room [ROOM NUMBER] found patient on floor - called for nurse and CNAs - they came and helped her. (sic) Witness statement of LPN #3 (licensed practical nurse) included: After speaking will (sic) staff working on 11/5/17 when (Name) Resident #109 fell , her daughter had been here visiting, when she left (Name) Resident #109 tried to get OOB (out of bed) to go change her shirt because she had spilled something on it and wanted to change her shirt. Her call bell was within reach but she did not ring. Light was off when she was found. She was found @ (at) the bedside, said she was trying to get up to go change her shirt. Her bed alarm was sounding when nurse entered bedroom. A housekeeper alerted her that (Name) Resident #109 was @ her bedside on the floor. (Name) LPN #3 said @ first she had no complaints but shortly after started complaining of her hand hurting. Family wanted her sent to ER. She was sent and returned with a broken finger . This surveyor interviewed Other #1 on 4/4/18 at 9:05 a.m. regarding Resident #109's fall on 11/05/17. Other #1 stated, She (Resident #109) had been in her w/c. I had stopped in a few minutes earlier and spoke to her and her roommate like I always do. I was in room [ROOM NUMBER] cleaning, when I heard someone holler, Help, we need help in here. I ran to the room and she (Resident #109) was already on the floor. I ran and got the nurse. There was a low beeping (muffled), sounded like the batteries were going dead. I didn't know at the time it was an alarm. No I did not hear the beeping in the other room. I just heard someone yelling for Help. Documentation in the ER note dated 11/5/17 included: .Arrived per EMS (emergency medical services) with c/o of a fall and patient with hematoma to the left hand and c/o of left arm pain from the shoulder to the hand .bruising noted to the top of the left hand .Nondisplaced fracture of base of second metacarpal bone, left hand, initial encounter for closed fracture. The Resident Incident Report dated 11/7/17 at 12:30 a.m. included the following: Narrative of incident and description of injuries: Resident in w/c with alarm at nurses station. Resident stood up nurse ask her to sit down before she and CNAs could reach her she fell face forward to floor. (sic) Witness statement of CNA #2 included: I came in to work at 10pm. (Name) Resident #109 was in bed awake and moving around. Her bed alarm was going off. I got her to lay back down (Name) Resident #109 laid back down. She laid there for about 30 mins. Then she was setting back up in her bed. Got her to lay back down around 11:30pm. (Name) Resident #109 would not stay in bed and the aide (Name) got her up and put her in her wheelchair with her alarm on. While (Name) Resident #109 was setting at the nurse desk. She was very confused and very combative. At around 12:30 am on Tue [DATE] (Name) Resident #109 went to stand up and lost her balance and fell . I was running trying to get to her, but I could not get to her fast enough . Witness statement of LPN #2 included: I was in another residents room giving prn (as needed) pain med. CNA called me to come to nurses station. (Name) Resident #109 was in the floor on her back 2 CNA's and nurse were present. (sic) I assessed injuries .as we were sending her to ED . Witness statement of CNA #3 included: (Name) Resident #109 was in bed attempted to get up. Nurse (Name) LPN #1 asked me to assist her, so I went into the room she was trying to get her legs out of bed. (sic) I reminded her not to get up or she would fall. She wanted to get up. I then got her up put her in her wheelchair turned her alarm on and sit her in front of the nurses station the time was around 11:30 (sic) I was sitting around the nurses station on my 15 min break I was on the other side next to the med room. (sic) I heard her alarm go off I looked up and she was going down I knew it was late to get to her as she fell her head hit the floor (Name) LPN #2 was right there as soon as it happened along with (Name) CNA #2. (sic) That was 12:30 . Witness statement for LPN #1 included: While in was in (sic) med room I heard (Name) Resident #109 alarm going off. She was trying to get up. I tried to tell her that it was bedtime but she continued to try to get up. I asked (Name) CNA #3 if she could get her to go back to bed. (Name) CNA #3 got her up since she said that she wanted up. (Name) Resident #109 was brought up to the desk where we all was .She was agitated. (Name) Resident #109 started screaming that we had locked her up & (and) that she was a prisoner .She went to stand up from her w/c without assistance. I asked her if she could sit back down and she did. Suddenly then she jumped up and stepped 2 steps to her left with her legs crossed. Me (LPN #1) & (Name) CNA #3 and (Name) CNA #2 got her as quick as we could but I was within the nurse station . This surveyor interviewed CNA #2 on 4/4/18 at 2:40 p.m. regarding Resident #109's fall on 11/7/17. CNA #2 stated, I came on at 10:00 and got report from the off-going shift. Around 10-10:30, she was in bed. Around 11-11:30, she was trying to get up, kept sitting up making her alarm go off. (Name) CNA #3, the other girl working with me that night got her up and brought her to the nurse's desk in her w/c. She was agitated and restless. She was in her w/c sitting near the pantry door. I was sitting close to the clean utility room charting my ADL's. I had my chair positioned so I could see down the blue hall and the pink hall. I could see her from the waist up. I was able to see her because I am tall, not like the rest of them. I noticed she was leaning over in her w/c. I stood up to see and she stood up, took a couple of steps and fell on her face. I ran around the nurse's desk, but couldn't reach her fast enough. (Name) CNA #3 the other CNA was near the doctor's office and she ran towards her too, but couldn't reach her either. Normally we sit close to them, like in arms reach. I don't know why we weren't closer to her since she was so agitated and restless. That is a good question. LPN #1 was interviewed via phone on 4/4/18 at 3:20 p.m. LPN #1 stated, I was inside the nurse's station pulling charts or doing something with the charts. (Name) Resident #109 was sitting near the pantry in her w/c. I bent down to do something with a chart and when I stood up she was standing up. Before I could get out of the nurse's station and around to her, she fell . There were two aides outside of the nurse's station also. Normally someone is within arms reach. The two aides were outside the nurse's station. LPN #2 was interviewed via phone on 4/4/18 at 3:25 p.m. LPN #2 stated, I remember her being in the floor. I was in another resident's room giving a treatment when the aide came and got me. There was another aide and nurse with her. I knew he arm was broken because of how it was laying. We called 911. I feel they did the best they could with the 1:1. I remember she was extremely restless, like a jack in the box, up/down, up/down. She didn't want anyone touching her. She wanted her daughter and to go home. I probably would have called the daughters if she would have stayed that way, but I was giving nightly meds. She fell before I could call. I think they did the best they could. CNA #3 was interviewed via phone on 4/4/18 at 3:40 p.m. CNA #3 stated, I came into work at 10:00. She was restless, kept trying to get up, so we got her up in her w/c and brought her to the nurse's station because we were afraid she was going to fall. I was on the opposite side of the desk. The nurse kept telling her to sit down. I did not see the actual fall, but I heard it. I heard the nurse say, sit back down and then I heard her hit the floor. My back must have been turned at the time. I guess we weren't watching her at that moment. I don't remember if the alarm was going off or not. I just remember hearing her hit the floor. The nursing station was in the shape of a diamond, completely enclosed with a door between the North and West points of the diamond. The counters of the nurse's station were approximately four feet tall all the way around. Resident #109 was sitting in her w/c between the East and South point of the diamond. CNA #3 was near the West point of the diamond. CNA #2 was sitting between the North and West points of the diamond. LPN #1 was inside of the nurse's station with the door closed. As documented in the above interview with CNA #3, She was restless, kept trying to get up, so we got her up in her w/c and brought her to the nurse's station because we were afraid she was going to fall. The resident was not placed near anyone that could have maybe prevented or cushioned her fall. She was brought to the nurse's station in her w/c, left to sit alone with no one in close proximity to discourage her from getting up or prevent her from falling. Per the interview with CNA #3, My back must have been turned at the time. I guess we weren't watching her at that moment. Per the staff interview no one was watching the resident at the time of her fall. Documentation in the ER note dated 11/7/17 included: .presents to ED for complaint of right humerus pain and a laceration to the bridge of her nose after falling out of her wheelchair .This is her second fall in 2 days. She suffered a hand fx (fracture) on the first fall .This is the pts second fall in 36 hours. She was evaluated for the first fall and suffered metacarpal fx of the left hand. Today she suffered displaced fx of the right humeral neck and an abrasion/hematoma to the nose . The DON (director of nursing) was interviewed at 4:00 p.m. during a meeting with the survey team regarding Resident #109's fall on 11/7/17. The DON stated, I don't know what they were thinking. I guess they thought they would be able to get to her in time. No further information was received by the survey team prior to the exit conference on 4/4/18.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, facility staff failed to prevent one of 10 residents from two falls within 38 hours, both resulting in harm, Resident #109. Facility staff failed to ensure Resident #109's safety, resulting in two falls within 38 hours, both resulting in fractures. Findings included: Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a 14-day assessment with an ARD (assessment reference date) of 10/25/17. Resident #109 was assessed as moderately impaired in her cognitive status with a total cognitive score of nine out of 15. Resident #109's EMR (electronic medical record) was reviewed on 04/03/18 at 2:05 p.m. During this review a Fall Risk assessment dated [DATE] showed a total fall score of 15. 10 or higher on the scale equaled high risk for falls. Section G - Functional Status on the MDS with an ARD of 10/25/17 included Resident #109 needed extensive assistance of two or more person physical assist with bed mobility and transfers; required extensive assistance of one person physical assist with locomotion on and off the unit; ambulation in her room or corridor was coded as did not occur. The CCP (comprehensive care plan) for Resident #109 included the following: .Problem Onset: 10/13/2017 FALL RISK Resident is at risk for falls r/t (related to) impaired cognitive status, left meniscus tear, left knee pain, weakness, and ataxic gait. Bed and w/c (wheelchair) alarms in place. Goal & Target DATE: Resident will not experience injury from a fall requiring ED (emergency department)/hospitalization through next review. Approaches: Keep bed in lowest position with wheels locked .Keep call light within reach and encourage resident to call for assistance as needed .Ensure resident is wearing proper footwear when out of bed .Monitor for changes in health condition, ie increased confusion .Assist resident as needed with ADLs, transfers, and mobility .Ensure bed and w/c alarms are on and working properly at all times . Both falls, 11/5/17 and 11/7/17, were listed on the CCP, but no other interventions were added to the care plan. Nursing Progress Notes included the following documentation: 11/5/17 10:29 a.m. - RSD (resident) found in the bed room floor with bed alarm sounding. no (sic) complaints of pain or discomfort . 11/5/17 11:12 a.m. - rsd (sic) sent to ED (emergency department) per RP (responsible party) request d/t (due to) left wrist pain . 11/5/17 2:40 p.m. - .rsd (sic) is 1-person assist with ADL (activities of daily living) transfers .Scheduled pain meds held per family. She returned to the facility from (Hospital Initials) at 1400 (2:00 p.m.). She is s/p (status [REDACTED]. 11/5/17 10:32 p.m. - .Resident is 1-2 person for ADLs and transfers. Resident is alert to self only and is confused. Resident is also post fall. Resident fell on morning shift and has a left metacarpal fx (fracture). Resident has complained of pain and discomfort during the shift .Resident pulled the tempory (sic) cast off of her arm . 11/6/17 4:14 a.m. - .Resident S/P fall and ER visit on 11/5, left arm soft splint cast intact at this time. Resident agitated at beginning (sic) of shift, .attempted to self transfer several times, resident assisted up to w/c (wheelchair) and placed at nurses station for supervision .Safety reminders provided, however due to residents dementia unable to show understanding .Safety measures in place . 11/6/17 2:08 p.m. - .Resident is alert with confusion .S/P fall and ER visit with L (left) metacarple (sic) fx. Soft splint cast to LUE (left upper extremity) is C/D/I (clean/dry/intact) .Requires 1 with ADLs/transfers . 11/7/17 4:12 a.m. - Around 2330 (11:30 p.m.) this nurse heard resident's bed alarm sounding. This nurse went into pt's room, pt was trying in get up from bed. (sic) Attempted to redirect pt about going back to bed since it was bedtime. This nurse was not successful. CNA (certified nursing assistant) was asked to help redirect pt. Resident was gotten up in w/c and positioned at nurses' station with staff. Resident was very confused and yelling with her nurse, stating she was in a prison. fell ow nurse asked if pt was in pain and tried to assess pt, resident became more aggressive and combative. Resident did eventually calm down. At about 2430 (12:30 a.m.), this nurse was in nurses' station checking charts when this nurse noted that the pt was trying to stand up from w/c. This nurse asking pt to sit back down (sic), resident did sit was down in chair (sic). Resident quickly then jumped up from w/c and stepped 2 steps to her left with her legs twisted. At that time, this nurse and 2 CNA tried to get around the nurses' station to resident but was unsuccessful. Resident had fallen face first to floor infront (sic) of pantry door. Resident's alarm was sounding once was on the ground (sic). Resident has (sic) laying on her right side and blood was coming from the top of her nose. Both CNAs was with resident while this nurse went to get the nurse for the pt. 11/7/17 7:38 a.m. - Resident on floor from fall lying on her back. evaluated (sic) residents visible injuries. resident (sic) had abrasion on her nose that was bleeding, subsided with pressure. skin (sic) tear on lf (left) elbow bleeding applied dry dressing. abrasion (sic) to left knee and bruising appearing. resident (sic) has right arm partially under her, unable to move arm without pain .resident very vocal and confused .911 called and resident transferred to (Hospital Name) ED . The Resident Incident Report dated 11/5/17 at 10:00 a.m. including the following: .Narrative of incident and description of injuries: RSD found in floor with bed alarm sounding .No injuries. Witness statement of Other #1 included: Heard a cry for help. Went to room [ROOM NUMBER] found patient on floor - called for nurse and CNAs - they came and helped her. (sic) Witness statement of LPN #3 (licensed practical nurse) included: After speaking will (sic) staff working on 11/5/17 when (Name) Resident #109 fell , her daughter had been here visiting, when she left (Name) Resident #109 tried to get OOB (out of bed) to go change her shirt because she had spilled something on it and wanted to change her shirt. Her call bell was within reach but she did not ring. Light was off when she was found. She was found @ (at) the bedside, said she was trying to get up to go change her shirt. Her bed alarm was sounding when nurse entered bedroom. A housekeeper alerted her that (Name) Resident #109 was @ her bedside on the floor. (Name) LPN #3 said @ first she had no complaints but shortly after started complaining of her hand hurting. Family wanted her sent to ER. She was sent and returned with a broken finger . This surveyor interviewed Other #1 on 4/4/18 at 9:05 a.m. regarding Resident #109's fall on 11/05/17. Other #1 stated, She (Resident #109) had been in her w/c. I had stopped in a few minutes earlier and spoke to her and her roommate like I always do. I was in room [ROOM NUMBER] cleaning, when I heard someone holler, Help, we need help in here. I ran to the room and she (Resident #109) was already on the floor. I ran and got the nurse. There was a low beeping (muffled), sounded like the batteries were going dead. I didn't know at the time it was an alarm. No I did not hear the beeping in the other room. I just heard someone yelling for Help. Documentation in the ER note dated 11/5/17 included: .Arrived per EMS (emergency medical services) with c/o of a fall and patient with hematoma to the left hand and c/o of left arm pain from the shoulder to the hand .bruising noted to the top of the left hand .Nondisplaced fracture of base of second metacarpal bone, left hand, initial encounter for closed fracture. The Resident Incident Report dated 11/7/17 at 12:30 a.m. included the following: Narrative of incident and description of injuries: Resident in w/c with alarm at nurses station. Resident stood up nurse ask her to sit down before she and CNAs could reach her she fell face forward to floor. (sic) Witness statement of CNA #2 included: I came in to work at 10pm. (Name) Resident #109 was in bed awake and moving around. Her bed alarm was going off. I got her to lay back down (Name) Resident #109 laid back down. She laid there for about 30 mins. Then she was setting back up in her bed. Got her to lay back down around 11:30pm. (Name) Resident #109 would not stay in bed and the aide (Name) got her up and put her in her wheelchair with her alarm on. While (Name) Resident #109 was setting at the nurse desk. She was very confused and very combative. At around 12:30 am on Tue [DATE] (Name) Resident #109 went to stand up and lost her balance and fell . I was running trying to get to her, but I could not get to her fast enough . Witness statement of LPN #2 included: I was in another residents room giving prn (as needed) pain med. CNA called me to come to nurses station. (Name) Resident #109 was in the floor on her back 2 CNA's and nurse were present. (sic) I assessed injuries .as we were sending her to ED . Witness statement of CNA #3 included: (Name) Resident #109 was in bed attempted to get up. Nurse (Name) LPN #1 asked me to assist her, so I went into the room she was trying to get her legs out of bed. (sic) I reminded her not to get up or she would fall. She wanted to get up. I then got her up put her in her wheelchair turned her alarm on and sit her in front of the nurses station the time was around 11:30 (sic) I was sitting around the nurses station on my 15 min break I was on the other side next to the med room. (sic) I heard her alarm go off I looked up and she was going down I knew it was late to get to her as she fell her head hit the floor (Name) LPN #2 was right there as soon as it happened along with (Name) CNA #2. (sic) That was 12:30 . Witness statement for LPN #1 included: While in was in (sic) med room I heard (Name) Resident #109 alarm going off. She was trying to get up. I tried to tell her that it was bedtime but she continued to try to get up. I asked (Name) CNA #3 if she could get her to go back to bed. (Name) CNA #3 got her up since she said that she wanted up. (Name) Resident #109 was brought up to the desk where we all was .She was agitated. (Name) Resident #109 started screaming that we had locked her up & (and) that she was a prisoner .She went to stand up from her w/c without assistance. I asked her if she could sit back down and she did. Suddenly then she jumped up and stepped 2 steps to her left with her legs crossed. Me (LPN #1) & (Name) CNA #3 and (Name) CNA #2 got her as quick as we could but I was within the nurse station . This surveyor interviewed CNA #2 on 4/4/18 at 2:40 p.m. regarding Resident #109's fall on 11/7/17. CNA #2 stated, I came on at 10:00 and got report from the off-going shift. Around 10-10:30, she was in bed. Around 11-11:30, she was trying to get up, kept sitting up making her alarm go off. (Name) CNA #3, the other girl working with me that night got her up and brought her to the nurse's desk in her w/c. She was agitated and restless. She was in her w/c sitting near the pantry door. I was sitting close to the clean utility room charting my ADL's. I had my chair positioned so I could see down the blue hall and the pink hall. I could see her from the waist up. I was able to see her because I am tall, not like the rest of them. I noticed she was leaning over in her w/c. I stood up to see and she stood up, took a couple of steps and fell on her face. I ran around the nurse's desk, but couldn't reach her fast enough. (Name) CNA #3 the other CNA was near the doctor's office and she ran towards her too, but couldn't reach her either. Normally we sit close to them, like in arms reach. I don't know why we weren't closer to her since she was so agitated and restless. That is a good question. LPN #1 was interviewed via phone on 4/4/18 at 3:20 p.m. LPN #1 stated, I was inside the nurse's station pulling charts or doing something with the charts. (Name) Resident #109 was sitting near the pantry in her w/c. I bent down to do something with a chart and when I stood up she was standing up. Before I could get out of the nurse's station and around to her, she fell . There were two aides outside of the nurse's station also. Normally someone is within arms reach. The two aides were outside the nurse's station. LPN #2 was interviewed via phone on 4/4/18 at 3:25 p.m. LPN #2 stated, I remember her being in the floor. I was in another resident's room giving a treatment when the aide came and got me. There was another aide and nurse with her. I knew he arm was broken because of how it was laying. We called 911. I feel they did the best they could with the 1:1. I remember she was extremely restless, like a jack in the box, up/down, up/down. She didn't want anyone touching her. She wanted her daughter and to go home. I probably would have called the daughters if she would have stayed that way, but I was giving nightly meds. She fell before I could call. I think they did the best they could. CNA #3 was interviewed via phone on 4/4/18 at 3:40 p.m. CNA #3 stated, I came into work at 10:00. She was restless, kept trying to get up, so we got her up in her w/c and brought her to the nurse's station because we were afraid she was going to fall. I was on the opposite side of the desk. The nurse kept telling her to sit down. I did not see the actual fall, but I heard it. I heard the nurse say, sit back down and then I heard her hit the floor. My back must have been turned at the time. I guess we weren't watching her at that moment. I don't remember if the alarm was going off or not. I just remember hearing her hit the floor. The nursing station was in the shape of a diamond, completely enclosed with a door between the North and West points of the diamond. The counters of the nurse's station were approximately four feet tall all the way around. Resident #109 was sitting in her w/c between the East and South point of the diamond. CNA #3 was near the West point of the diamond. CNA #2 was sitting between the North and West points of the diamond. LPN #1 was inside of the nurse's station with the door closed. As documented in the above interview with CNA #3, She was restless, kept trying to get up, so we got her up in her w/c and brought her to the nurse's station because we were afraid she was going to fall. The resident was not placed near anyone that could have maybe prevented or cushioned her fall. She was brought to the nurse's station in her w/c, left to sit alone with no one in close proximity to discourage her from getting up or prevent her from falling. Per the interview with CNA #3, My back must have been turned at the time. I guess we weren't watching her at that moment. Per the staff interview no one was watching the resident at the time of her fall. Documentation in the ER note dated 11/7/17 included: .presents to ED for complaint of right humerus pain and a laceration to the bridge of her nose after falling out of her wheelchair .This is her second fall in 2 days. She suffered a hand fx (fracture) on the first fall .This is the pts second fall in 36 hours. She was evaluated for the first fall and suffered metacarpal fx of the left hand. Today she suffered displaced fx of the right humeral neck and an abrasion/hematoma to the nose . The DON (director of nursing) was interviewed at 4:00 p.m. during a meeting with the survey team regarding Resident #109's fall on 11/7/17. The DON stated, I don't know what they were thinking. I guess they thought they would be able to get to her in time. No further information was received by the survey team prior to the exit conference on 4/4/18.

Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of two complaint investigations, the facility staff failed to accurately assess and provide treatment and services for the prevention and/or healing of pressure ulcers for three of 21 residents (Resident #258, Resident # 259 and Resident #56), with resulting harm for one (Resident #258). This is a complaint deficiency. 1. Facility staff did not assess Resident #258's sacral wound for ten days. From [DATE] until [DATE], the wound increased from 2.60 cm X 1.30 cm X .10 cm to an unstageable with measurements of 7.0 cm X 5.0 cm X .10 cm. Additionally, when the assessment was completed on [DATE], an additional seven Stage I pressure ulcers were assessed and documented on the facility wound assessment report. Two of the identified Stage I pressure ulcers progressed to Stage II pressure ulcers when reassessed on [DATE]. 2. Resident #259 was admitted to the facility with orders for a wound vac to treat a Stage IV pressure ulcer. The wound vac was not put into place for two days. The pressure ulcer was never assessed by the facility, nor did the facility notify the attending physician that the wound vac was unavailable. 3. Resident #56 was not wearing physician ordered geri sleeves or heel protectors. Findings were: 1. Facility staff did not assess Resident #258's sacral wound for ten days. From [DATE] until [DATE], the wound increased from 2.60 cm X 1.30 cm X .10 cm to an unstageable with measurements of 7.0 cm X 5.0 cm X .10 cm. Additionally, when the assessment was completed on [DATE], an additional seven Stage I pressure ulcers were assessed and documented on the facility wound assessment report. Two of the identified Stage I pressure ulcers progressed to Stage II pressure ulcers when reassessed on [DATE]. Resident #258 was originally admitted to the facility on [DATE], she was most recently readmitted on [DATE] and died in the facility on [DATE]. Her [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE], identified Resident #258 as having difficulty with both long and short term memory, as well as being severely impaired with daily decision making skills. Resident # 258 was being followed by Hospice. A progress note from the nurse practitioner dated [DATE] contained the following information: Skin Breakdown S (subjective): [AGE] year old [MEDICAL CONDITION] hx (history) on Hospice with 5 new area of skin breakdown since last week. Area on sacrum was old and was felt to be improving several wks ago. Staff are not sure how new areas occurred. O (objective):there is an old necrotic area on sacrum and new area to L (left) of this on L buttock. There is a reddened area R (right) hip with a small area of breakdown, there are new areas across tops of L toes and sides of feet bilaterally. Allevyn are knocked wounds and she is not wearing her heel guards. A (assessment): Skin breakdown, multiple new areas P (plan): Wt loss with poor nutrition and advanced [MEDICAL CONDITION] are contributing. Will call Hospice RN and discuss. The wound records were reviewed. A Wound Assessment Report dated [DATE] was reviewed. The following information was observed: Wound Type: Pressure Ulcer Wound Location: Sacrum Wound Status: Improved Stage: Unstageable due to slough/eschar Measurements: Length: 2.60 cm Width: 1.30 cm Depth: .10 cm Notes: Rsd with unstageable wound of sacrum. There is no exudate present. There is no indication of pain. Rsd is tolerant of tx (treatment) to area. Rsd is compliant with turning and repositioning q2h to offload pressure to area. RP (responsible party) and MD notified, no changes warranted. The next Wound Assessment Report was dated [DATE] and contained the following information: Wound Type: Pressure Ulcer Wound Location: Sacrum Wound Status: Deteriorated Stage: Unstageable due to slough/eschar Measurements: Length: 7.00 cm Width: 5.00 cm Depth: .10 cm Notes: Rsd with unstageable wound of sacrum. There is a small amount of serosanguineous exudate present. There is a 3.5 x 3.0 cm area of black necrosis. Rsd is tolerant of tx to the area. RP and MD notified. No changes warranted to treatment. Rsd with order to be turned and repositioned q2h while in bed. Rsd with no complaints of pain at his time. Area has deteriorated. Rsd is Hospice patient healing is not expected in this setting. Palliative care is the goal for this resident. Additionally the following new areas of pressure were identified and documented on Wound Assessment Records on [DATE]: 1. Wound Type: Pressure Ulcer Wound Location: Right hip Date Wound Identified: [DATE] Assessment Occasion: New Wound Stage: I Measurements: Length: 5.0 cm Width: 3.5 cm Notes: Rsd with Stage I of R hip. Area is non blanchable. There is no indication of pain at this time. Rsd is tolerant of tx to area. Rsd with order to be turned and repositioned q2h while in bed to assist in offloading pressure to the area, RP and MD notified. 2. Wound Type: Pressure Ulcer Wound Location: Left Buttock Date Wound Identified: [DATE] Assessment Occasion: New Wound Stage: I Measurements: Length: 3.50 cm Width: 6.50 cm Notes: Rsd with Stage I non blanchable area to L buttock. Area is area of preexisting wound. There is no indication of pain at this time. Rsd is tolerant of tx to area. Rsd with order to turn and position q2h while in bed to assist in offloading pressure to the area, RP and MD notified. 3. Wound Type: Pressure Ulcer Wound Location: Right Lateral Malleolus Date Wound Identified: [DATE] Assessment Occasion: New Wound Stage: I Measurements: Length: 3.00 cm Width: 3.00 cm Notes: Rsd with Stage I non blanchable area to R ankle. There is no indication of pain at this time. Rsd is tolerant of tx to area. Rsd is compliant with wearing prevalon boots. Rsd with order to turn and position q2h while in bed to assist in offloading pressure to the area, RP and MD notified. 4. Wound Type: Pressure Ulcer Wound Location: Right 5th Toe, R lateral side of foot behind 5th digit Date Wound Identified: [DATE] Assessment Occasion: New Wound Stage: I Measurements: Length: 2.50 cm Width: 2.0 cm Notes: Rsd with Stage I non blanchable area to lateral side of R foot behind fifth digit. There is no indication of pain at this time. Rsd is tolerant of tx to area. Rsd with order to turn and position q2h to assist in offloading pressure to the area, RP and MD notified. 5. Wound Type: Pressure Ulcer Wound Location: Right 5th Toe Date Wound Identified: [DATE] Assessment Occasion: New Wound Stage: I Measurements: Length: 1.00 cm Width: 0.50 cm Notes: Rsd with Stage I of R 5th metatarsal that is non blanchable. There is no indication of pain at this time. Rsd is tolerant of tx to area. Rsd with order to turn and position q2h while in bed to assist in offloading pressure to the area. Rsd is complaint with wearing prevalon boots. RP and MD notified. 6. Wound Type: Pressure Ulcer Wound Location: Left Great Toe Date Wound Identified: [DATE] Assessment Occasion: New Wound Stage: I Measurements: Length: 3.00 cm Width: 3.00 cm Notes: Rsd with Stage I of L Great Toe. Area is nonblanchable. There is no indication of pain at this time. Rsd is tolerant of tx to area. Rsd with order to turn and position q2h while in bed to assist in offloading pressure to the area. Rsd is compliant with wearing prevalon boots. RP and MD notified. 7. Wound Type: Pressure Ulcer Wound Location: Right Great Toe Date Wound Identified: [DATE] Assessment Occasion: New Wound Stage: I Measurements: Length: 2.50 cm Width: 3.00 cm Notes: Rsd with Stage I of R Great Toe. Area is non blanchable. There is no indication of pain at this time. Rsd is tolerant of tx to area. Rsd with order to turn and position q2h while in bed to assist in offloading pressure to the area. Rsd is complaint with prevalon boots. RP and MD notified. On [DATE] Wound Assessment Records were completed and contained the following: 1. Wound Type: Pressure Ulcer Wound Location: Left Great Toe Date Wound Identified: [DATE] Assessment Occasion: Weekly Update Stage: 2 Measurements: Length: 2.50 cm Width: 1.50 cm Depth: 0.10 Notes: Rsd seen by wound specialist for Stage 2 of L distal medial foot. There is no indication of pain. There is no exudate present. Rsd is tolerant of tx to area. Rsd is palliative care, healing/improvement is not expected in this setting. RP and MD notified. 2. Wound Type: Pressure Ulcer Wound Location: Right Great Toe Date Wound Identified: [DATE] Assessment Occasion: Weekly Update Stage: 2 Measurements: Length: 3.00 cm Width: 2.00 cm Depth: 0.10 Notes: Rsd seen by wound specialist for Stage 2 of R great toe There is no indication of pain. There is no exudate present. Rsd is tolerant of tx to area. RP and MD notified. Rsd is palliative care, healing/improvement is not expected in this setting. 3. Wound Type: Pressure Ulcer Wound Location: Right 5th Toe, R distal lateral foot and 5th toe Date Wound Identified: [DATE] Assessment Occasion: Weekly Update Stage: I Measurements: Length: 4.50 cm Width: 1.00 cm Notes: Rsd seen by wound specialist for right distal leateral (sic) foot and fifth digit Stage I. There is no exudate present. There is no indication of pain. There is no exudate present. Rsd is tolerant of tx to area. RP and MD notified. The physician order [REDACTED]. Bed side fall mat. On [DATE] the following orders were written: Turn Q2h (every 2 hours) when in bed . Apply skin prep to Stage I R hip qd (every day) apply skin prep to stage I of L buttock qd, Apply skin prep to stage I of R side of R 5th metatarsal foot qd, apply skin prep to stag I of side of R great toe qd, apply skin prep to Stage I to side of L great toe qd .prevalon boots at all times, bed cradle at all times. The above information was discussed with the DON (director of nursing) and the wound nurse. Concerns were voiced by this surveyor that a wound assessment had not been conducted for ten days and when it was completed on [DATE] the sacral wound had deteriorated, increased in size and the resident had multiple new areas. The wound nurse stated, I was off the week of (MONTH) 4th .when I came back in on that Monday ([DATE]) the new areas were there .while I was off that week she (Resident #258) fell .they took her off of her air mattress and put her on a concave mattress .we think that might be why she developed the areas. The DON was asked what the expectation was regarding the frequency of wound assessments. She stated,Weekly .every seven days. The DON was asked if a span of ten days would be considered too long. She stated, Yes. The wound nurse and the DON also directed this surveyor to an additional report in the clinical record regarding wound assessment. Further review of the electronic clinical record was conducted. Skin Inspection Reports were observed. The following information was collected on skin inspection report: Assessment Date, Skin Status and Entered By. Entries on electronic record for this screen were: [DATE] Skin Not Intact-Existing; [DATE] Skin Not Intact-Existing; [DATE] Skin Not Intact-New. All entries were signed by the wound nurse. The DON came to the conference room to speak with this surveyor. She was asked how the wound nurse had completed a Skin Inspection Report on [DATE] when she was on vacation. The DON left the conference room. When she returned she stated, (Name of Wound Nurse) didn't do the skin inspection report on [DATE], (name of former DON) did it, she gave the information to (name of the wound nurse) and she recorded it . The DON was asked if that was acceptable practice. She stated, No. The DON was asked if the information was accurate. She stated, I don't know. The concave mattress order was also discussed. An order on the clinical record dated [DATE] was: (Change symbol) mattress to concave mattress on bed with air flow . The DON was asked what a concave mattress with air flow was. She stated, They don't exist .they took her off of the air mattress and put her on the concave mattress because of her falls .when the new areas were discovered, she was put back on the air mattress .I can't find an order for [REDACTED].>LPN (licensed practical nurse) #4 was interviewed on [DATE] at approximately 2:00 p.m. regarding the concave mattress order that she had transcribed. She stated, I thought that was the kind of mattress that hospice used. According to the TAR (treatment record) LPN #4 had performed dressing changes to Resident #258's sacral area during the time that the wound nurse had been off. She was asked if she had measured the area during any of the dressing changes. She stated, No, Usually the wound nurse does rounds with the wound doctor and do measurements .I guess when she's off the nurse's could do it. The Hospice nurse who cared for Resident #258 was interviewed via telephone on [DATE] at approximately 2:45 p.m. She was asked about Resident #258's pressure areas in relation to her [DIAGNOSES REDACTED]. The hospice nurse stated, We looked into this after it happened .the pressure areas that developed were not the type of pressure ulcers that are considered to be nutritionally related like a Kennedy ulcer .these were definitely pressure related . the resident had fallen .the facility put her on a concave mattress and that may have been a contributing factor it's like laying them in a gutter . The nurse practitioner who was seeing the resident was interviewed on [DATE] at approximately 3:00 p.m. regarding her note written on [DATE] regarding Resident #258's new pressure areas. She stated, She was declining rapidly, she was bed ridden and immobile .when I was there she was always in the bed or the wheelchair .I was very surprised when they told me she was trying to get up and had fallen .I don't know how she was getting out of the bed. The nurse practitioner was asked if she thought the areas were unavoidable. She stated, I don't know what to say to that she had a lot going on that predisposed her but that was a lot of breakdown in a short amount of time .I really can't say if they were unavoidable or not. The facility policy, Wound Care was obtained. According to the policy, All assessment data (i.e. wound bed color, size, drainage, etc) will be obtained weekly and documented in the medical record. During an end of the day meeting the above information was discussed with the DON and the administrator. Concerns were voiced that Resident #258's sacral wound had not been assessed for ten days and when the assessment was completed on [DATE] the wound had deteriorated. Concerns were voiced that in spite of daily dressing changes to the sacral wound, there was no documentation in the clinical record describing the change in the appearance or increase in size of the wound. Concerns were also voiced that there was no evidence that Resident #258 had been assessed after the change in her mattress and when the wound nurse returned on [DATE] there were multiple new pressure areas. The DON and the administrator were informed that the survey team had identified the deficient practice as possible harm. No further information was obtained prior to the exit conference on [DATE]. This is a complaint deficiency. 2. Resident #259 was admitted to the facility with orders for a wound vac to treat a Stage IV pressure ulcer. The wound vac was not put into place for two days. The pressure ulcer was never assessed by the facility, nor did the facility notify the attending physician that the wound vac was unavailable. Resident #259 was added to the survey sample as a closed record due to a complaint received at the Office of Licensure and Certification, alleging that a wound vac was not implemented per physician's orders [REDACTED]. Resident #259 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Stage IV pressure ulcer of left ankle, Spinal stenosis, Chronic Ischemic [MEDICAL CONDITION], hypertension and SIADH ( syndrome of inappropriate antidiuretic hormone secretion). Resident #259 was discharged from the facility on [DATE], no MDS (minimum data set) information was obtained. The clinical record was reviewed beginning [DATE]. The progress note section of the clinical record contained the following nursing documentation: [DATE] 2:29 p.m. Resident admitted to room [ROOM NUMBER] A from (name of local hospital). Resident arrived to facility at 1335 (1:35 p.m.) via w/c (wheelchair) via (name of transportation company) with sister-in-law accompanying. Resident is an [AGE] year old female alert and oriented to person and place only with admitting [DIAGNOSES REDACTED].Dimes size scab with redness around it noted to R (right) pinky knuckle, pencil eraser size purple discoloration noted to pointer knuckle, fifty cent piece size skin tear noted to L wrist, dime size purple discoloration noted to LFA (left forearm), pencil eraser sized scattered scabs noted to R knee, wound vac noted to L ankle ulcer, multiple discolorations noted to R ABD (abdomen), quarter size redness noted to L back of shoulder/neck area, and redness noted to bottom .MD/RP aware of admission. Addendum [DATE] 3:19 p.m Correction: Pencil eraser size purple discoloration noted to R pointer knuckle, fifty cent piece size purple discoloration noted to LFA and L AC (antecubital). [DATE] 4:57 a.m. Rsd (resident) continues as skilled for wound care Wound vac dressing to left ankle clean, dry and intact. Rsd continues on 1 liter fluid restriction . [DATE] 2:26 p.m. Resident is skilled for wound care to L ankle. [DATE] 6:40 p.m. Resident is skilled for wound care to L ankle . [DATE] 4:39 a.m. Rsd continues as skilled for wound care .wet to dry dressing to left ankle clean, dry, intact. Rsd continues on 1 liter fluid restriction . [DATE] 2:02 p.m. Resident is skilled for wound care to L ankle . [DATE] MD in on rounds today. New admission evaluation completed with new orders .elevate LE BID (lower extremities two times per day)for one hour . [DATE] 7:06 p.m. Resident is skilled for wound care to L ankle .wound vac in place and working properly . [DATE] 2:19 p.m. Rsd skilled for left ankle ulcer .Rsd was transported to (name of local hospital) ED (emergency department) at 1400 (2:00 p.m.,) for cough, SOB (shortness of breath), difficulty breathing and ,[DATE]+ LLL (left lower leg) [MEDICAL CONDITION] and redness . [DATE] 10:18 p.m. Resident was admitted to (name of local hospital) for suspected [MEDICAL CONDITION], SOB and cough. Discharge instructions from the hospital were reviewed. Under the section Wound Care, the following was documented: Wound vac changed on Mon, Wed, Fri. Duoderm dressing changed on Mon and Fri. The facility physician orders [REDACTED]. The care plan was reviewed. There were no interventions on the initial care plan regarding Resident #259's wound, wound vac or wound care. Additional documentation regarding Resident #259 was requested from the local hospital and received on [DATE]. Included in information received was an email between the hospital discharge planner and the facility's admission director. Included in the email was the following information: Hospital discharge planner: 'Also, (name of Resident #259) will still need her wound vac when she comes to you. Just a head's up' (smiley face symbol). Facility admissions director: 'Perfect- she will be in room [ROOM NUMBER] A and (name of physician) will be her attending' (smiley face symbol) On [DATE] at approximately 11:30 a.m., LPN (Licensed Practical Nurse) #4 was interviewed regarding the admission note she wrote on [DATE]. She was asked specifically about the reference to wound vac noted to L ankle ulcer in her note. She stated, I remember that because I got a corrective action for what I wrote .the wound vac wasn't here .the dressing was there and the tubing was in place at admission but there wasn't a wound vac and there wasn't one here .they didn't send one from the hospital with her .we called the doctor and he said it was Ok to place it (the wound vac) the next day .I documented the wound vac was there but it was really just the dressing . LPN #4 reviewed the documentation in the clinical record. She stated, We got an order to do a wet to dry dressing on (MONTH) 15 .I don't remember if she ever got the wound vac or not. LPN #4 was asked how she knew what a resident was going to need when they arrived at the facility. She stated, We get information from admissions about who's coming, their name and room they are going to. LPN #4 was asked how the facility got admission orders [REDACTED]. LPN #4 was asked if anyone contacted the hospital to let them know that a wound vac was not on site. She stated, I don't see anything about it in the documentation and I don't know who notified them that we didn't have a wound vac, but I'm pretty sure we contacted the hospital. At approximately 1:50 a.m., the wound nurse was interviewed regarding Resident #259's wound vac. She stated, We didn't know that she was coming with a wound vac .The hospital didn't send the wound vac with her .they rent them from a company and didn't know how to transfer the rental from the hospital to here .We got orders for a wet to dry dressing. We called (name of company) to get a wound vac here but they said we wouldn't get it until the 16th so (name of admissions person) went and got it. I looked there is no documentation in the record that we contacted the physician we should have contacted the doctor on (MONTH) 14th when she got her .I don't see that documented but we did get an order for [REDACTED]. LPN # 1 (MDS) was interviewed at 12:45 p.m. She stated, I don't know who reviewed the admission information before she (Resident #259) got here. We didn't know she had a wound vac .the admitting nurse documented that there was a wound vac in place but it was really just the dressing .the hospital wouldn't give us their wound vac so (name of supply person) contacted whoever we get our equipment from .she got a wound vac through a company in Salem so (name of former admissions director) went and got it. LPN #1 was asked if she felt the facility should have sent the resident back to the hospital since they didn't have the proper equipment in house to care for her. She stated, Yes, we should have. LPN #1 was asked about Resident #259's care plan. She stated, She wasn't here for 14 days so the comprehensive care plan was not done .the initial care plan should have included the wound care and the wound vac. At approximately 1:30 p.m., the person who gets supplies for the facility, OS (other staff) # 3 was interviewed. She stated, We did have a wound vac here when the resident arrived .when they hooked it up, it didn't work. I called (name of company) and they said it would take ,[DATE] hours to get one here .we called another company and they could get it here quicker .they had a guy bring it here, it wasn't (name of admissions director) .we called the hospital before we did any of that and they wouldn't give us a wound vac because the one they had was under their rental agreement with the company. The above interviews were discussed with the DON and the documentation from the hospital was shown to her regarding the fact that the admissions coordinator did know about the wound vac. She shook her head side to side. Further review of the clinical record was conducted. There were no wound assessments located in the clinical record. The DON was asked if there were any additional areas where the wound documentation might be located. She reviewed the closed record and stated that she had also not located any assessments of the wound. She was asked what the expectation was regarding wound assessments. She stated, The wound should have been assessed on admission or as soon as the dressing was removed. A note from the attending physician was observed. The note written [DATE] contained the following information: Jun 16, (YEAR) Fri 11:40 a.m. [AGE] year old WF admitted after acute hospitalization for [MEDICAL CONDITION], pressure ulcer with [MEDICAL CONDITIONS] had been receiving care for an anterior tibial ulcer with unna boots. Developed pressure area anterior ankle .was admitted (to the hospital) for IV antibiotics and wound care .she was treated with a wound vac. Had an appt with vascular ,[DATE] and planned debridement then wound vac for a few weeks again before graft. She has not had wound vac on since Wednesday ([DATE]). Facility not aware that she required one. MD at site (facility) changed dressings to wet to dry and wound vac ordered. At facility now.Will admit for wound care. Wound vac in place at this point. Elevate LE . The facility policy, Pressure Ulcer/Skin Breakdown-Clinical Protocol contained the following: The staff will examine the skin of a new admission for ulcerations or alterations in skin. The emergency department note from [DATE] was reviewed and contained the following information: .presents with chief complaint of a cough that preludes dyspnea, but states to be the same for 2 years. Nursing home staff report patient to be short of breath with low Os saturations in the 80's .(Daughter states cough is worse than usual) .Treatments and ED course: .introduced self and discussed pan with family. They are currently upset with care received at (name of facility). States patient has been sitting with legs down in front of nurse's desk and mess hall. Claim patient's wound vac was not in place for several days. Have called (name of facility) supervisors for complaints. Have made multiple requests for (name of attending) to call and discuss care with staff, but has been unable to reach physician .Final Impression: Acute combined systolic and diastolic heart failure . On [DATE] at approximately 3:30 p.m., the attending physician for Resident #259 was interviewed via telephone. She was asked about Resident #259's wound and the care provided at the facility. She stated, I did the admission exam on (MONTH) 16 .I didn't know about the wound vac .I wasn't contacted that the wound vac wasn't there .the admission coordinator and the DON decide if a patient can come to the facility and they are accepted if we can provide the care needed. The attending physician was asked if she felt Resident #259 was provided the care needed and if she should have been accepted to the facility. She stated, No, she should not have been admitted .when it was determined that there was no available wound vac she should have been sent back to the hospital .no one contacted me .they contacted (name of another physician) and he gave them patch through orders until the wound vac could arrive. The attending physician was asked if she felt that Resident #259 was readmitted to the hospital with [REDACTED]. She stated, I can't comment on the [MEDICAL CONDITION] or the heart failure .I would need to review the hospital records .certainly her situation at the facility was not ideal. The above information was discussed with the DON and the administrator during an end of the day meeting on [DATE]. No further information was received prior to the exit conference on [DATE]. This is a complaint deficiency. 3. Resident #56 was not wearing physician ordered geri sleeves or heel protectors. Resident #56 was most recently admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A 5 day MDS (minimum data set) assessment, coded Resident #56 with a cognitive summary score of 12, indicating she was moderately impaired. On [DATE] 4:25 p.m. Resident #56 was observed sitting up in a wheelchair in her room. Her daughter was in the room visiting. A family interview was conducted. Resident #56 was observed wearing Bilateral Geri sleeves. The clinical record was reviewed on [DATE] at approximately 8:00 a.m. Observed on the POS (physician's orders [REDACTED]. On [DATE] 08:53 AM Resident #56 was observed in bed. Her geri sleeves were not on. She was asked if she was wearing her heel protectors. She stated, No. She was asked if she had requested not to wear them. She stated, No, sometimes they put them on me and sometimes they don't. I don't mind wearing them. Resident #56 was asked about her geri sleeves. She stated, They took them to wash. [DATE] 2:00 p.m. Resident #56 was observed in bed, her geri sleeves were in place. Resident #56 was asked if she was wearing her heel protectors. She stated, No, they didn't put them on me today. This surveyor went to the nurse's station and spoke with CNA (certified nursing assistant) # 2, who took care of Resident #56 on dayshift. She was asked about Resident #56's heel protectors. She stated, I didn't put them on her .they weren't on earlier when I came in and I just didn't think about it when I put her back to bed. CNA # 2 was asked how she knew what care to provide for residents. She stated that there was a Kardex care plan in each resident's closet. This surveyor and CNA #2 went to Resident #56's room and looked at the Kardex. Heel protectors were listed on the CNA's Kardex to be applied as tolerated. The heel protectors were observed in the closet, CNA #2 stated, I will put them on her now. The above information was discussed during an end of the day meeting with the DON (director of nursing) and the administrator on [DATE]. No further information was obtained prior to the exit conference on [DATE].

Based on observation, staff interview, clinical record review, and in the course of a complaint investigation, the facility failed to ensure one of 21 residents in the survey sample's meal intake was assessed prior to administration of insulin resulting in harm Resident # 108; and also failed to follow physician orders [REDACTED].# 259 and # 23. 1. Resident # 108 was administered [MEDICATION NAME] (a long-acting insulin) at 8:00 p.m. without assessment of meal intake resulting in a hypoglycemic extremely low blood sugar) event which resulted in hospitalization and harm. 2. Resident # 259's physician ordered fluid restriction was not monitored. 3. Resident # 23 did not have TED hose applied as ordered by the physician. Findings include: 1. Resident # 108 was administered 27 units of [MEDICATION NAME], a long-acting insulin, without being assessed for meal intake which resulted in harm. Resident # 108 was sent to the emergency room (ER) with loss of consciousness after being found at 1:20 a.m. on 11/11/17 with a blood sugar reading of 33. Resident # 108 was admitted to the facility 12/3/13 with a readmission date of [DATE]. It should be noted here Resident # 108 signed herself out AMA (against medical advice) 11/14/17. There was no MDS (minimum data set) information available as Resident # 108 was in the facility less than 14 days for completion of an admission assessment. Resident # 108 was assessed by nursing staff as alert with some confusion but able to make needs known. During review of the clinical record 2/8/18 at approximately 2:00 p.m. it was noted a nurses' note dated 11/11/17 at 4:52 a.m. 1:20 a.m. resident found to be sweeting (sic) and unresponsive. Blood sugar 33. one unit dose of [MEDICATION NAME] administered. 1:40 a.m. blood sugar 54, loc (level of consciousness) unchanged, breathing uneven and labored. vs (vital signs): 184/85 bp, 69 pulse, 12 respiration, 97.5 temp, 87% oxygen (O2) . Oxygen 2 lpm (liters per minute) administered via nasal cannula. 1:50 a.m. blood sugar 72, remains unresponsive. Covering physician (name of physician) telephone order to send to ER. Transported to hospital at 2:10 a.m. via ambulance. Resident was not appropriately responsive or alert when she left facility. ER staff informed of pending arrival and status. Daughter, second listed for RP, notified of having been sent to ER. 4 am informed by ER staff of pending return, having had administered box lunch and ensure. Attending physician recommends primary physician review insulin orders, with attention to administration when refusal to eat meal. Resident returned to facility with daughter via personal car. 5:20 am refused vitals. Blood sugar 329, O2 89% placed on 2 lpm concentrator O2 via nasal cannula. Resident alert and oriented to person and place, with appropriate response and interactions. will continue to observe. The meal intake roster was then reviewed and revealed the resident was documented as having eaten 5% - 25% of breakfast and lunch 11/10/17, and had refused dinner. Documented out from the refusal to eat dinner was in large type NOTIFY NURSE. Further review of the clinical record failed to reveal if the nurse was notified of the resident refusing dinner, or the nurse verifying with the resident the meal consumption, or documentation from the physician regarding the event, including any changes in insulin administration with regards to the resident refusing meals. On 2/9/18 at approximately 10:45 a.m. the hospital records were reviewed for the ER visit 11/11/17. The attending physician documented the admitting [DIAGNOSES REDACTED]. Pt. from (name of facility), complaint of [DIAGNOSES REDACTED], blood sugar 33, pt given [MEDICATION NAME], blood sugar up to 72. Pt. placed on O2 for pulse ox of 87% per nursing home staff. O2 98% on arrival Blood sugar 84 by accucheck. Pt. awake and moaning on arrival .Pt. ate entire ensure, half sandwich and most of pineapple cup. States didn't have supper this past evening. Discharge documentation included Have PMD (primary medical doctor) review dietary and insulin requirements. Do a point of care glucose meter prior to administration of insulin. (Do not administer insulin if patient is not eating). On 2/12/18 at 10:45 a.m. the DON (director of nursing) was made aware of the above findings. The DON reviewed the clinical record and stated Yes, looks like that's exactly what happened. This surveyor asked the DON for the following information: did staff notify the nurse of resident refusing dinner 11/10/17, did the nurse verify meal status prior to administration of insulin, and did the physician review insulin orders. The DON stated she would see what she could find out and get back to me. On 2/12/18 at 4:00 p.m. the DON told this surveyor I cannot find any other information about the nurse being told the resident did not eat her dinner. I have paged the doctor but have not heard from her yet. It doesn't appear the nurse knew the resident didn't eat, and it doesn't appear the nurse asked the resident about her meal intake before giving the insulin; one staff is only here occasionally and unable to reach the other staff. I hate it, but it looks like it went exactly as you have found. On 2/12/18 during a meeting with facility staff beginning at 4:30 p.m. the administrator and DON were informed of the above findings and the concern of resultant harm to the resident. The administrator and DON verbalized understanding. No further information was provided prior to the exit conference. 2. Facility staff failed to assess and monitor a physician ordered 1000 cc fluid restriction for Resident #259. Resident #259 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Stage IV pressure ulcer of left ankle, Spinal stenosis, Chronic Ischemic [MEDICAL CONDITION], hypertension and SIADH ( syndrome of inappropriate antidiuretic hormone secretion). Resident #259 was discharged from the facility on 06/17/2017, no MDS (minimum data set) information was obtained. The clinical record was reviewed beginning 02/07/2018. Discharge instructions from the hospital were reviewed. Under the section What To Do At Home, the following was listed: Fluid Restrictions: 1 liter fluid restriction. The baseline care plan was reviewed. There were no interventions on the initial care plan regarding fluid restrictions. The physician order [REDACTED]. The TAR (treatment administration record) and the MAR (medication administration record) for (MONTH) was reviewed. There were no entries on either regarding Resident #259's fluid restrictions. On 02/12/2018 the DON (director of nursing) was asked how fluid restrictions were monitored at the facility. She stated that there was an intake and output flow sheet that the staff completed. She stated she would look to see what she could find for Resident #259. The DON came to the conference room at approximately 9:00 a.m. and stated, You're not gonna like what I have to say, but I can't find anything showing where her (Resident #259) fluid intake was tracked. The DON was asked what the expectation was for a Resident ordered a 1000 cc fluid restriction. She stated, They need to write it down and track it. The above information was discussed with the DON and the administrator during an end of the day meeting on 02/12/2018. No further information was received prior to the exit conference on 02/12/2018. 3. The facility staff failed to ensure Resident # 23's physician ordered TED hose were applied to bilateral lower extremities. Resident # 23 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident as having a cognitive score of 12, indicating the resident had moderate impairment in daily decision making skills. The resident was also assessed as requiring extensive assistance for most ADL's (activities of daily living) including dressing and hygiene. Resident #23 was observed and interviewed on 02/07/18 09:31 AM in his room. The resident was sitting in his w/c and had bilateral hand/arm protectors on. The resident's legs were observed and appeared swollen. The resident stated that they were and pulled up his left pant leg, exposing his lower left leg. The resident's leg was a dark ruddy color with [MEDICAL CONDITION] noted. The resident then pulled up his right pant leg and stated, This one's not as bad. 02/07/18 11:00 AM Resident # 23 physician's orders [REDACTED]. 02/09/18 11:54 AM Resident #23 was interviewed regarding the TED hose and his leg swelling. The resident stated that he wanted to get back on his feet and wanted the swelling in his legs to go down and asked what he could do about it. The resident was asked if he had TED hose for his legs for the swelling. The resident stated, No. The resident was informed that he had an order for [REDACTED]. The resident was asked if staff had been putting them on him or attempting to put them on him. The resident stated, No. The resident was then asked if, staff had asked him or attempted to put on the TED hose and again the resident stated, no. The resident was asked if staff had offered to put the TED hose on him and he refused or told staff that he did not want them. The resident stated, no again and again verbalized that he wanted to get it 'worked on' and he would be willing to try them, but the TED hose had not been offered. On 02/09/18 11:58 AM LPN (Licensed Practical Nurse) # 2 was interviewed and asked if Resident # 23 had an order for [REDACTED]. The LPN stated that the night shift get him up and she was not sure who that was. The LPN was then asked, where the documentation for the TED hose application would be. LPN # 2 asked LPN # 3 who was standing at the nurses station, 'would that be in the CNA documentation' and then asked, 'where is the documentation for that?' LPN # 3 stated, 'the nurse's do it.' Both LPN's were then asked if that would on the MAR (medication administration record) or the TAR (treatment administration record). LPN # 3 stated that it is on the TAR. LPN # 2 was then asked for a copy of the TAR for (MONTH) for the TED hose application for Resident # 23. The resident has been observed through out the survey process from 02/06/18 up to present 02/09/18 12:06 PM without any TED hose on. The TAR documented (with staff initials) giving the indication that the TED hose had been applied and removed as ordered for each day of the month of (MONTH) (1st through 9th). The resident did not had the TED hose applied during multiple observations throughout the survey process on 02/06/18 through 02/09/18. Nursing notes were then reviewed for the month of February, no information and/or documentation was found regarding the resident's TED hose application, removal of and/or refusal. The CCP (comprehensive care plan) was reviewed and documented in several 'problem areas' that the resident is to have bilateral TED hose per physician's orders [REDACTED].TED hose per current order . The resident's last update on the CCP for TED hose was dated on 08/26/17. The resident did not have a current wound on either leg. The above information was shared with the DON (director of nursing) and the administrator in a meeting with the survey team on 02/12/18 at approximately 4:30 p.m. No information and/or documentation was presented prior to the exit conference on 02/12/18 at 6:45 p.m.

Based on observation, family interview, staff interview, and clinical record review, the facility staff failed to ensure one of 13 residents in the survey sample (Resident # 101) maintained acceptable nutritional parameters. The facility staff failed to implement nutritional recommendations from Speech Therapy for 1:1 supervision at meals. Finding include: Resident # 101 was admitted to the facility on [DATE], with the most current readmission on 06/18/13. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) with CAAS (care area assessment summary) was the admission assessment dated [DATE]. This MDS assessed the resident with short and long term memory impairment with moderate impairment in daily decision making skills. The resident was also assessed as requiring extensive assistance with most all ADL's (activities of daily living) with at least one person physical assist, including eating/meal consumption. The CAAS was triggered for nutrition to be care planned. A quarterly MDS assessment dated [DATE], was reviewed for comparison and assessed the resident with cognitive score of "0/0" indicating the resident was severely impaired cognitively. The resident was assessed on this MDS as requiring limited assistance with consuming meals with the help of one staff person physical assist. On 01/28/14, Resident # 101's clinical record was reviewed (electronic and hard copy records). The following was revealed: A "Dietary Note" dated 01/08/14 documented: "...CBW (current body weight): 125.6...Resident receives med pass 120 cc (cubic centimeters) tid (three times a day) for nutritional support...Resident has been observed eating her mech soft diet with her fingers at times which prompted nursing to generate a referral to speech therapist. ST (Speech Therapist) to evaluate and recommend dietary changes as deemed appropriate...At this time recommend offering high protein mech soft snacks bid (twice daily) between meals...Therapeutic weight gain would be beneficial to resident (3-5 X 90 days)...signature of RD (Registered Dietitian)." A "Therapy Note" dated 01/09/14 documented: "...Clinical eval (evaluation) of swallow, Minutes-41, Quality-1, Please refer to the medical record for the therapy daily treatment documentation. Evaluation for change to finger food diet with a one time staff education/in service training...signature of ST (Speech Therapist)." A "Dysphagia Evaluation" documented: "...Onset: 01/06/14 Eval Date: 01/09/14...Res (resident) tolerating mech soft, thins with no signs of airway violation, however not using utensils and only using fingers. increased time to complete a meal with refusal to be fed...(Positioning during eval): 90 degrees at dining room table, (consistencies evaluated): mechanical soft (cognition and safety awareness): poor-fair. Clinical Summary: Res observed with breakfast tray. Refusal to use utensils with difficulty navigating tray. Used fingers for PO/self feeding, even when prompted to use utensils. Mechanical soft finger foods with thins recommended. Staff educated re: putting mech (mechanical) soft meat on bread to make into finger foods...Swallowing Recommendations Post Eval: PO (by mouth) Supervision: 1:1 (one to one) Solid Consistency: mech soft finger foods...Long term goals: to be achieved by 01/09/14-Increase PO intake and self feeding status...Potential for Achieving Goals: Excellent Increase PO/Feeding...signature of ST (01/09/14)...signature of Physician (01/14/14)" Resident # 101's CCP (comprehensive care plan) was reviewed and documented: "..Problem onset: 01/16/14...At risk for compromised nutritional status and hydration status secondary to history of significant weight loss...Monitor weight per facility policy, monitor food texture tolerance...supplements per orders...OT (occupational therapy) and ST (speech therapy) to screen as needed...Diet clarification: Mechanical soft finger foods with thin liquids to encourage self feeding, offer high protein snacks BID (twice daily) between meal nutritional support, Incourage (sic) PO intake at meals with cues and assist resident with feeding as needed as resident allows, encourage fluids..." A "Dietary Note" dated 01/22/14 documented: "Resident diet changed to from (sic) Finger foods to Mech soft due to resident's increased acceptance of feeding assistance. Resident has fair PO intake at 50%...signature of RD." A "Dietary Note" dated 01/23/14 documented: "...CBW: 117.4 lbs. ...weight loss 6.5 % x (times) 14 days...offering protein snacks between meals. Recommend adding magic cup bid (twice daily) at lunch and dinner...signature of RD." A "Nursing Note" dated 01/28/14 documented: "...Resident weekly weight completed today 116.2 ...will continue to monitor...signature of DON (director of nursing)." On 01/29/14 at approximately 12:25 p.m., Resident # 101 was observed sitting in the dining room at a table with her husband and two other individuals. The resident's husband was seated to resident's anatomical right side. Resident # 101 was sitting in her w/c (wheelchair) intermittently leaning her head onto her right hand. The resident had a hearing aide in the left ear. The resident's tray was observed to have approximately 10 % eaten from it. The resident's tray consisted of small pieces of cubed chicken pieces with gravy on top, mashed potatoes, green beans, a roll, applesauce and a "magic cup." Upon entry into the dining room, the resident's husband stated to this surveyor, "Honey, can you feed her." The resident's husband further stated that he could not really assist her with feeding that he was "too nervous" and held up his hands to show the movement of his hands. The resident's husband further stated that "she needs to eat, she has lost a lot of weight since she's been here, somebody needs to feed her...I only ask of a few things of them (the facility), that they keep her clean, feed her and give her something to drink..." At approximately 12:35 p.m. the DON (director of nursing) came over to the table and spoke to the resident and began to assist the resident with bites. The resident took several bites and occasionally pushed away. The resident's husband prompted, saying "take a bite...you want a bite, take another bite..." The husband then began attempting to feed his wife and the wife began taking bites. The DON got up and left the table within a few minutes. The resident's husband stated that she (the resident) had drank two cups of water and one cup of kool-aid (6 ounces each). At 12:50 p.m., the husband was still attempting to feed the resident, 25 minutes after the initial surveyor observation, with approximately 40% of the meal being consumed. At 1:00 p.m., the corporate nurse entered the dining room and offered to help assist the resident. At 1:10 p.m., the corporate nurse was still assisting the resident with her meal. The meal observation was completed at this time with approximately 65 to 75% of the meal consumed. A copy of the resident's CCP was requested from the corporate nurse at approximately 2:00 p.m. The CCP was presented and reviewed and documented two hand written entries updating this CCP, "01/28/14 Resident has tendency to eat with fingers...Encourage resident to use eating utensils and respect resident's right to eat with fingers." At 2:50 p.m. in a meeting with the survey team, the administrator was made aware of the above observation, in addition to the findings in the clinical record regarding Resident # 101's ST recommendation/physician's orders [REDACTED]. The administrator stated that today (01/29/13) was the resident's and her husbands anniversary and that he requested to sit at a different table. The administrator was informed that the resident's husband had asked this surveyor to feed the resident. The administrator stated that staff were available in the dining room. At 4:20 p.m., the ST was made aware of the observation and was interviewed with the survey team regarding Resident # 101. The ST stated that the resident has a tendency to "eat with her fingers and that meal consumption takes extended amounts of time." The ST also stated that the resident usually sits at supervised dining room table and it's easier to encourage her to eat. The ST further stated that the resident needs more than "periodic checks and is 1:1...she (the resident) would need encouragement and supervision if at another table." The ST was asked about the husband assisting the resident. The ST stated that she felt comfortable with the husband assisting, but "I'd hope staff are going to take over, not him to encourage her." The ST was asked what the purpose of the 1:1 was for Resident # 101. The ST stated, "For PO intake and nutrition...not safety." No further information or documentation was provided prior to the exit conference on 01/29/14 at 5:15 p.m.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure three of 16 residents maintained acceptable parameters of nutritional status (Resident # 6, Resident # 2 and Resident # 13). 1. The facility staff failed to appropriately identify Resident # 6's weight loss, assess and implement interventions for the prevention of weight loss, and failed to the monitor Resident # 6 for acceptable nutritional parameters. Resident # 6 had a significant weight loss of 17.1 lbs (pounds) from 03/05/13 through 06/05/13 (greater than a 10% loss in 3 months) without any assessment or nutrition intervention to prevent further loss. Facility staff further failed to act upon recommendations made on 09/25/13 to liberalize the resident's diet and increase nutrition supplementation. From September 2013 to the time of the survey Resident #6 continued to lose weight. 2. The facility staff failed to implement a nutrition intervention for Resident # 2 as recommended by the RD (Registered Dietitian) on 05/28/13. Med Pass nutrition supplement was not implemented until 11/15/13, almost 6 months after the recommendation. No other interventions were implemented for Resident # 2 and the resident continued to lose weight. 3. The facility staff failed to implement a nutrition intervention of Med Pass 90 cc (cubic centimeters) TID (three times per day) for Resident #13. The Med Pass was recommended 10/23/13 and was never initiated. Findings include: 1. Resident # 6 was admitted originally to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) with CAAS (care area assessment summary) was a significant change assessment dated [DATE]. The resident was assessed as having a cognitive score of 15, indicating the resident was cognitively intact. The resident was also assessed as requiring extensive assistance from staff for most all ADL's (activities of daily living). The resident was assessed on this MDS as requiring supervision with one staff person physical assist for eating. A comparative MDS (quarterly assessment) dated 11/12/13 was reviewed and assessed the resident with a cognitive score of 12, which indicated the resident was cognitively intact. During clinical record review on 12/10/13, Resident # 6's weight records were reviewed. The following were documented: 03/05/13 = 142.5 lbs (pounds) 04/05/13 = 137.2 lbs 05/06/13 = 131.8 lbs 05/21/13 = 129.8 lbs 06/05/13 = 125.4 lbs 07/02/13 = 123.6 lbs 07/09/13 = 119.0 lbs 07/18/13 = 117.6 lbs 08/06/13 = 118.4 lbs 09/16/13 = 118.8 lbs 10/22/13 = 116.8 lbs 11/05/13 = 115.6 lbs 12/03/13 = 114.6 lbs Resident # 6 experienced a significant weight loss of 17.1 lbs or 12% from 03/05/13 through 06/05/13. Resident #6 continued to lose weight and experienced a total loss of 27.9 lbs or 20% from 03/05/13 up to present (12/03/13). The Dietary section of the clinical record was then reviewed for Resident # 6 and documented: "Nutrition Care Quarterly Follow up...03/04/13...Diet order: NAS (No Added Salt)...Weight Loss: No or unknown...Problems: at risk for weight loss...Goals: no s/s (signs or symptoms) of weight loss X (times) 90 days...Approaches: weights as order (sic) diet as order (sic)...signature of Dietary Manager (03/04/13) and signature of RD (Registered Dietitian) 03/06/13. "Nutrition Care Quarterly Follow up...06/04/13..Diet order: NAS...Weight Loss: No or unknown...Problems: at risk for weight loss due to po (by mouth) intake...Goals: no significant weight loss X (times) next 90 days...Approaches: weights monthly, monitor po intake, diet as order (sic)...signature of Dietary Manager (06/04/13) and signature of RD 06/05/13. The resident's weight was 137.2 lbs on 04/05/13 and 131.8 lbs on 05/06/13. There was no mention of the resident's weight loss of 5 lbs in 1 month or 10.7 lbs in 2 months (8% weight loss in 2 months) or any assessment or recommendations made at this time to prevent further weight loss. A departmental note dated 06/04/13, documented: "...weight is 131.8 on therapeutic diet with intake 26-50% with refusing some meals...signature of Dietary Manager..." A "Dietary Consult" dated 07/18/13 documented: "...PO intake down...weight loss greater than 5% in 30 days...weight 119.0...Initiate Med Pass 60 cc (cubic centimeters) BID (twice per day) - nutritional support...Consider [MEDICATION NAME] secondary to Depression diagnosis...Consider Appetite stimulant secondary for poor po intake with depression diagnosis-Add supplement for nutritional support. Monitor PRN (as needed)...signature of RD." Current physician's orders [REDACTED]. Another "Nutrition Care Quarterly Follow up" documented: "...09/03/13..Diet order: NAS...Snacks: offer...Weight Loss: Yes, not physician-prescribed weight loss regimen...No or unknown...Problems: at risk for aspiration due to dysphagia...Goals: no signs or symptoms of aspiration X (times) 90 days...Approaches: diet as order(sic)...signature of Dietary Manager (09/03/13). A departmental note documented: "...09/04/13 weight 118.4 down 90 and 180 days...signature of Dietary Manager..." Another "Dietary Consult" dated 09/25/13 was reviewed and documented: "...weight 118.8...weight loss greater than 5% in 30 days...Initiate/Increase Med Pass 60 cc BID PO to 90 cc TID (three times a day) PO- nutritional support...Liberalize diet change to Regular, D/C (discontinue) NAS...Liberalize diet to encourage PO intake, Increase Med Pass to nutritional support...signature of RD." A departmental note dated 09/25/13, documented: "...118.8 BMI (body mass index) WNL (within normal limits) at 21.7 weight loss x 180 days po intake poor at 25-50 % diet: NAS. Recommend liberalize diet to Regular and discontinue NAS. also increase med pass from 60 cc bid to 90 cc tid for nutritional support will follow up prn...signature of RD." Resident # 6's physician's orders [REDACTED]. No order or evidence was found that Resident # 6 ever received the recommended diet liberalization or the increase nutritional supplement (med pass) as described above. A departmental note dated 10/09/12, documented: "...weight loss x 180 days weight stable x 30 days continue poc (plan of care) and follow up as needed...signature of RD." Resident # 6's CCP (comprehensive care plan) with a start date of 02/01/11 was then reviewed and documented: "06/11/13...At risk for compromised nutritional and hydration status...Resident will remain +/- (plus or minus) 5 pounds...weights per facility policy...Diet per MD (medical doctor) order...Labs per MD order...Dietary supplements per MD order...Resident feeds self independently after tray set up...Encourage diet as ordered...." Additionally on this CCP it was documented: "....06/05/13 significant weight loss X 90 days on plan, 07/05/13 weight down 9.9 % X 90 days- weight down 13/9 % X 180 days on plan, 08/05/13 weight down 10.2 % X 90 days and 15.5 % in 180 days, 09/05/13 weight down 14.7 X 180 days...(updated 09/16/13)." A new CCP dated 11/26/13 documented: "...Therapeutic diet, History of significant weight loss...no significant weight loss/gain through next review...weights per policy...diet per MD order...Supplements per MD order (see MAR (medication administration record)...Monitor labs as ordered..." Lab results for Resident # 6 were requested from the nurse consultant on 12/11/13. Lab results were presented for Resident # 6 and reviewed. The results documented: "...04/14/13...Total Protein = 6.0 (range 6.0-8.3)[MEDICATION NAME] = L (Low) 3.1 (range 3.2-5.5)..." physician progress notes [REDACTED]. 02/28/13-"...weight 140...no new orders, adjust pain meds as needed..." 04/12/13-"...weight 135.8...add [MEDICATION NAME]..." 06/07/13-"...? more depressed...looks fatigued, pale..." 06/10/13-"...pneumonia..." 07/06/13-"...pale...pneumonia ? resolving..." 07/12/13-"...Declining a bit low energy increased fatigue..." 08/30/13-"...per nursing po intake and energy level perking up...dementia...continue to maximize nutrition." 10/04/13-"...Family/staff note increased confusion she sometimes has hallucinations that bother her today she is alert and mildly confused...dementia consider [MEDICATION NAME] or antipsychotics..." 10/21/13-"...pain but doesn't seem acutely different no behaviors or distressful confusion, says she has pneumonia did several months ago...weight 121.0 (11% loss over past 6 months but stable from last month and up 3 pounds from 2 months ago)...dementia-likely longstanding but more evident...overall seems stable..." On 12/10/13 at 12:00 (noon) a dining room observation was made. Resident # 6 was observed sitting at a table with five other residents. No staff were seated at the table. Resident # 6 picked at her food intermittently, eating small bites for approximately 25 minutes. No staff interacted with the resident, there was no prompting or encouragement from staff with the meal. Staff were observed to walk by the table several times during the observation. The resident had a cookie that was wrapped in a wax paper pouch, the resident got the cookie out of the pouch after approximately 5 to 7 minutes. The resident's total meal intake was approximately 25-30%. On 12/10/13 at approximately 5:20 p.m., the administrator, the DON (director of nursing), and the nurse consultant were made aware of multiple concerns regarding Resident # 6, in a meeting with the survey team. The facility staff informed the survey team that the current Dietary Manager was recently hired and was not the one whose notes were referenced above. On 12/11/13 at approximately 11:45 a.m., the RD was interviewed in a meeting with the survey team. The RD was asked if she was aware of Resident # 6's significant weight loss. The RD stated, "No, (she was) not on the monthly weight report..." The RD was asked if any lab work had been recommend for the resident or if labs received had been reviewed. The RD stated, "No, not normally...if there is a skin issue (yes)..." The RD stated that she had not seen the resident and that she (RD) normally just goes by the chart. The RD was asked if she had ever watched Resident # 6 eat for assessment purposes in determining the resident's nutritional needs. The RD stated, "No Ma'am." The RD stated, "...that's more of a rehab issue..." The RD was asked regarding communication between herself (the RD) and the physician, nurses, and therapy staff. The RD stated, "I rarely talk to the MD, I just go by the chart and go by what they (staff) tell me on an as needed basis..." The RD was asked if there was a reason for the lack of communication regarding pertinent issues with the residents. The RD stated, "...that's just the way it's been done." The RD was asked, "Do you think it's working (lack of communication)?" The RD stated, "Apparently not." The RD stated that she (the RD) gets a list of resident's who have lost weight each month and that is how she is informed of a problem. The RD stated that she (the RD) does not keep any records or running tallies of weight loss for residents. The RD was asked if a resident is on the list one month and not the next, what happens? The RD stated that if they are not on the list the next time, then "...I assume they are no longer a problem..." The RD was asked how does she follow up to see if recommendations from her are implemented, such as the med pass for Resident # 6 that was recommended to be increased from 60 ml BID to 90 ml TID and the diet liberalization. The RD stated, "I have to trust the people I work with (to follow through)." The RD further stated that she does not have any input on the CCP, other than writing in the notes to continue the plan of care, along with any new recommendations. The administrator, DON, and the nurse consultant were again made aware of serious concerns regarding Resident # 6's significant weight loss and declining condition in a meeting with the survey team on 12/11/13 at approximately 3:40 p.m. The above interview was discussed with the facility staff. No comments were made by the administrative team. Information was requested at this time regarding the responsibilities/expectations of the RD. At approximately 5:10 p.m., the administrator presented information regarding the services to be provided by the RD. The document stated: "...The Dietitian shall provide the following services...review charts for nutritional assessments...review all charts for nutritional documentation and provide documentation as needed and/or required...participate in interdisciplinary care planning...document all exceptions to care plan when nutritional status is compromised...consult with administrator, nursing services and medical staff as appropriate...visit the patients on a regular basis, depending upon their needs and level of care to discuss problems with diet and food preferences and recommend appropriate methods for solving those problems...observe and interact with residents during meal service...review all records kept by FSM (food services manager)/DM (dietary manager)...plan and conduct monthly inservice programs...Evaluate the quality of food served to the resident to include: temperature, texture, appearance, and taste..." No further information or documentation was provided prior to the exit conference on 12/11/13 at 7:00 p.m. 2. Resident # 2 was admitted to the facility on [DATE], with the most current readmission on 06/18/13. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) with CAAS (care area assessment summary) was the admission assessment dated [DATE]. This MDS assessed the resident with short and long term memory impairment with moderate impairment in daily decision making skills. The resident was also assessed as requiring extensive assistance with most all ADL's (activities of daily living) with at least one person physical assist, including eating/meal consumption. The CAAS was triggered for nutrition on this MDS to be care planned. A comparison MDS, a quarterly assessment dated [DATE], assessed the resident with short and long term memory impairment and moderate impairment in daily decision making skills. The resident was assessed on this MDS as requiring limited assistance with consuming meals with the help of one staff person physical assist. During clinical record review on 12/010/13, Resident # 2's weight loss records were reviewed. The following was documented: 06/18/12 = 133.2 lbs 07/16/13 = 131.2 lbs 08/26/13 = 130.4 lbs 09/17/13 = 128.0 lbs 10/22/13 = 124.4 lbs 11/05/13 = 124.4 lbs 12/03/13 = 124.4 lbs Resident # 2's dietary/nutritional notes were then reviewed. A "Nutritional Admission Assessment" was completed on the resident on 05/23/13 (for original admission on 05/20/13). This assessment documented: "...weight loss: no or unknown...Current weight 149...alert/confused...Dietary intake: Poor...Problems: at risk for weight loss due to poor intake...Goals: No signs or symptoms of weight loss X (times) next review...Approaches: diet as ordered monitor po (by mouth) intake, offer alternatives, have RD eval for supplements...signature of DM (Dietary Manager) 5/23/13 and RD (05/28/13). A departmental note documented: "05/28/13-resident with poor intake at risk for weight loss. diet: regular consistency. recommend adding med pass supplement for nutritional support and have speech therapist eval due to poor denition (sic). will follow up prn (as needed)...signature of RD." This departmental note dated 05/28/13 did not specify the amount or frequency of the med pass recommendation. A departmental note documented: "06/04/13-137.8 on regular diet and eats 25-75%...no chewing...swallowing problems...signature of Dietary Manager..." A departmental note documented: "06/25/13-133.2 on a mechanical altered diet requires moist foods with gravy being on the side...Seen by ST (speech therapy) who downgraded diet...noted resident with pocketing food being fatigue and needing cues to swallow and clear...signature of DM." A departmental note documented: "07/15/13-129.8 on a regular diet with no chewing...swallowing problems at this time...signature of DM." A departmental note documented: "08/15/13-132.6 stable on a mechanical altered diet with no chewing...swallowing issues at this time...signature of DM." Resident # 2's physician's orders [REDACTED]. The resident's MAR's (medication administration records) was then reviewed and confirmed that Resident # 2 did not start receiving the recommended med pass until 11/15/13, almost 6 months after being recommended. physician progress notes [REDACTED]. "06/21/13 Admit: ...advanced dementia..." "08/29/13...continues to be stable..." "09/12/13...No changes accordingly to staff, except patient has been refusing meds.." "11/14/13...Overall patient seems to be doing well...she really was not interested in talking to be (sic) today. She was finishing her lunch...General: sitting a (sic) lunch table eating pushed me away when trying to listen to heart and lungs. No further exam completed..." The resident's CCP (comprehensive care plan) was then reviewed and documented: "...At risk for unplanned weight loss due to poor po intake...Incourage (sic) PO intake at meals with cues, encourage fluids, monitor weight per facility policy, monitor food texture tolerance...monitor and document changes in mood, appetite..." On 12/10/13 at 12:00 (noon) a dining room observation was completed. Resident # 2 was sitting at a table with four other residents, two staff members and a student nurse. The student nurse was sitting next to Resident # 2 assisting another resident. The student nurse had her back toward Resident # 2. Resident # 2 was eating macaroni and cheese with her fingers and would occasionally take a drink from a "sippy" cup. The staff at the table and the student nurse did not interact with the resident, no encouragement or cues were offered. One observation was made of the student nurse sliding the "sippy" cup toward Resident # 2, so the resident could reach it. The observation was completed at 12:30 p.m. On 12/10/13 at approximately 5:20 p.m., the administrator, the DON (director of nursing), and the nurse consultant were made aware of the concerns regarding Resident # 2, in a meeting with the survey team. The facility staff informed the survey team that the current Dietary Manager was recently hired and was not the same Dietary Manager that made the above notes. The facility staff were informed that an interview with the RD would be needed as soon as possible. On 12/11/13 at 12:15 p.m., the RD was interviewed regarding Resident # 2. The RD was asked about the note written on 05/28/13 regarding the recommendation for the med pass, specifically why an amount and frequency was not mentioned. The RD stated, "...I didn't write it..." The RD was made aware that she (RD) signed the note from May 28th. The RD stated that she (the RD) doesn't keep a copy of recommendations made for her records, that she (the RD) just puts a note in the computer. The RD was made aware that nothing had been documented on Resident # 2 since August 15th and that no assessment had been completed since 05/23/13 (3 days after the resident's original admission of 05/20/13). The RD stated that an assessment should have been completed in October and as far as the notes, the Dietary Manager does those. The RD was asked why those were not done. The RD stated that she didn't know. In meeting with the survey team on 12/11/13 at approximately 3:40 p.m., the administrator, DON, and the nurse consultant were again made aware of concerns regarding Resident # 2 being identified as a nutritional risk, without appropriate and adequate interventions. At approximately 5:10 p.m., the administrator presented information regarding the services to be provided by the RD. The document stated: "...The Dietitian shall provide the following services...review charts for nutritional assessments...review all charts for nutritional documentation and provide documentation as needed and/or required...participate in interdisciplinary care planning...document all exceptions to care plan when nutritional status is compromised...consult with administrator, nursing services and medical staff as appropriate...visit the patients on a regular basis, depending upon their needs and level of care to discuss problems with diet and food preferences and recommend appropriate methods for solving those problems...observe and interact with residents during meal service...review all records kept by FSM (food services manager)/DM (dietary manager)...plan and conduct monthly inservice programs...Evaluate the quality of food served to the resident to include: temperature, texture, appearance, and taste..." No further information or documentation was provided prior to the exit conference on 12/11/13 at 7:00 p.m. 3. Resident # 13 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) with CAAS (care area assessment summary) was an annual assessment dated [DATE]. Resident # 13 was assessed with [REDACTED]. The resident was also assessed as requiring extensive assistance with ADL's (activities of daily living) from one to two staff members including transfers, dressing, and eating. Resident # 13 did not trigger for nutrition on this MDS. A comparison (quarterly) MDS dated [DATE] was reviewed. Resident # 13 was again assessed with [REDACTED]." The resident was assessed on this MDS as requiring limited assistance, with one person physical assistance for eating. On 12/10/13 at 12:00 (noon), Resident # 13 was observed in the dining room with her meal tray in front of her which consisted of a salmon patty, cooked zucchini squash, small cubed potatoes and a separate bowl of jello. The resident had no eating utensils. Resident # 13 was observed to sit, without speaking, intermittently looking at her tray of food and looking around in her general area. At approximately 12:10 p.m., a nursing student came over and sat beside the resident. The student looked directly at the resident, spoke a few words and then got up and moved to another table. A staff member came over to the table at about the same time and brought a drink to another resident sitting at the other end of the table. The resident continued to look around and down at her tray intermittently. The resident began picking up pieces of cooked zucchini squash with her fingers and ate it very slowly. At approximately 12:18 p.m., Resident # 13 had consumed all of the cooked squash with her fingers. The resident ate a few pieces of the small, cubed potatoes and did not touch the salmon patty. The resident still did not have any eating utensils. At 12:20 p.m., the resident pulled off her clothing protector from around her neck (with one hand) and laid it on the table and pushed the tray of food away from her. The resident then reached for the bowl of jello, held it in one hand, as she took her other hand and put it in the bowl scooping out the jello with her fingers and began eating it. At 12:30 p.m., CNA # 2 came over to the table and saw the resident eating the jello with her fingers. CNA # 2 took the bowl of jello from the resident and stated to the resident, "Where is your...?" The CNA then looked at this surveyor, nodded her head back and forth and told the resident she would get some silverware for her. The CNA left the table and the resident picked the bowl of jello back up and began eating it again with her fingers. When the CNA returned with the silverware, she placed the spoon in the bowl and left the table. The resident picked up the spoon and ate all of the jello that was left in the bowl, with the spoon. At approximately 5:30 p.m. on 12/10/13, the administrator, the DON (director of nursing), and the nurse consultant were made aware of the above observation. No comments were made. The administrative staff were informed of concerns and an interview was requested with the RD (Registered Dietitian) as soon as possible. On 12/11/13 at 8:00 a.m., Resident # 13's clinical record was reviewed. Resident # 13's weight records were reviewed and documented the following: 04/05/13 = 116.8 lbs 05/06/13 = 114.4 lbs 06/05/13 = 112.8 lbs 07/05/13 = 112.4 lbs 08/05/13 = 107.8 lbs 09/05/13 = 103.4 lbs 10/08/13 = 104.2 lbs "07/01/13...114.4...regular diet and eats 50% at most with refusing some meals. Resident loves hot dogs...Resident has no chewing or swallowing problems...Resident is fed on a red plate and uses red utensil due to bad eye sight...signature of DM." "09/30/13...107.4 no significant weight loss but weight trending downward...below IBW (ideal body weight)...no swallowing or chewing problems...signature of DM." "10/09/13...weight loss x (times) 180 days...continue poc (plan of care) and monitor prn (as needed)...signature of RD (Registered Dietitian)." A "Dietary Consult" dated 10/23/13 documented: "...PO intake down...Underweight BMI<20@17.2...weight loss 11.2 in 180 days...weight 103.4...PO Intake ~50%...Initiate Med Pass 90 cc (cubic centimeters) TID (three times per day) PO - nutritional support, weight loss...Finger food snacks between meals...supplement and snacks due to weight loss...signature of RD." A departmental note dated 10/23/13 documented "CBW (current body weight): 103.43 BMI<20@17.2. weight loss x 180 days...Regular finger foods. po intake only fair at 50%. recent appt (appetite) stimulant added. recommend adding med pass 90 cc tid and finger food snacks between meals to provide additional calories and encourage therapeutic weight gain (3-5# (pounds) x 90 days) will f/up prn...signature of RD." Resident # 13's current CCP (comprehensive care plan) was then reviewed and documented: "...Resident has inability to perform ADL's independently secondary to dementia and poor vision...Resident feeds self independently after tray set up, cue as needed and assist as needed...encourage diet as ordered, offer alternates for food dislikes..." Resident # 13's old CCP was reviewed (dated 01/31/11 through 10/11/13) and documented: "9/11/2013 Sig (significant) wt (weight) loss in 90 days...10/11/13 Sig wt loss in 180 days." There were no new approaches/interventions documented for these significant weight loss noted in September and October 2013. Resident # 13's current physician's orders [REDACTED]...06/19/12 (start date) [MEDICATION NAME] 15 milligrams PO (by mouth) 1 tab at bedtime every day DX (diagnosis) appetite stimulant..." No order or evidence was found that Resident # 13 ever received the recommended nutritional supplement (med pass) as described above. On 12/11/13 at approximately 11:20 a.m., the RD was interviewed. The RD was made aware of the observation of Resident # 13 eating with her fingers. The RD stated, that she (resident) is on prescribed finger foods. The RD was asked if zucchini squash was a finger food. The RD stated, "Yes." The RD was asked if it was on the finger food diet list, just presented. The RD stated, "No, but that's just a partial list..." The RD was asked if she (herself) considered over cooked zucchini squash to be a finger food. The RD stated, "...I wouldn't consider..." The RD was asked about the resident's salmon patty, cubed potatoes and jello as finger foods. The RD stated that the salmon patty is suppose to be "salmon bites", in small pieces (it was not) and that jello is a finger food. When asked again about the jello, the RD stated it is on the list. The RD was informed that it was regular jello, not the kind with gelatin in it (jello jigglers) that is formed and can be picked up. The RD agreed that, no regular jello is not a finger food. The RD was asked if someone is on a "finger food" diet would they be given eating utensils. The RD stated, "I don't see why you wouldn't have silverware." Again the administrator, DON, and nurse consultant were made aware in a meeting with the survey team at approximately 5:00 p.m. on 12/11/3. Again, no comments or information was shared by the administrative team. No further information or documentation was provided prior to the exit conference on 12/11/13 at 7:00 p.m.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide supervision and ensure safety devices were in place for two of 16 residents: Resident #8 and Resident #4. 1. Resident #8 was left unsupervised and was found in the floor of his room. The cord from the seat belt to the alarm box had been disconnected. Resident #8 sustained a hip fracture from the fall. 2. Resident #4 did not have bilateral fall mats in place at the bedside. Findings were: 1. Resident #8 was originally admitted to the facility on [DATE] and was readmitted on [DATE] following a right hip fracture. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 10/18/2013. Resident #8 was assessed as having a difficulty with both long and short term memory, as well as being moderately impaired with daily decision making skills. The clinical record was reviewed on 12/10/2013 beginning at approximately 10:30 a.m. The current care plan dated 10/21/13 documented a problem of "Leaning forward decreased (arrow down) safety awareness" with an approach of "...soft seat belt self release alarming ...when up in w/c..." A note documented "01/04/2013 10:19 p.m. at (sic) 17:30 (5:30 p.m.) resident was found sitting on the floor, in his room, initially, with no apparent injuries or skin breaks. the (sic) seat belt alarm was discovered as disconnected, at the box, from the wire to the belt. the (sic) staff varified (sic), the resident had already been in the hallways, and had once, set off his alarm, thus establishing fact, that the alarm was intact, when the resident was gotten up for supper. later (sic) after the incident, the resident did not have any appetite (very unusual for him), and was clammy with diaphoresis, at this point, the resident, seemed to respond to pain on the right side of is hip. the daughter was contacted by phone, and was very understanding of the incident. Doctor (name) provided an order to transfer to (name of hospital) ER (emergency room ). 911 was contacted, and the daughter expressed intention to travel there to be with her father, transport arrived at 19:00 (7:00 p.m.), with 2 assist, and a stretcher, for the transfer to (name of hospital) ER. the resident was admitted to (name of hospital) for a right hip fracture. the daughter was by his side, at the hospital, when the nurse called." The note was written by RN (registered nurse) #2. A copy of the facility investigation regarding the above was requested and received from the DON (director of nursing). at approximately 11:00 a.m. A single page was presented. The DON stated, "I am looking for the rest of it." The page presented was titled "American Healthcare/Heritage Hall Risk Management Tracking & Trending." Information on the form was divided into separate sections. The first section contained information regarding the facility name, resident name, room number, date and time of the even. Under the section "Description of Event" the following was written: "resident found sitting on floor 17:30 w/ (with) seatbelt alarm wire disconnected & not sounding. Resident had no appetite with diaphoresis. Sent to ER at 19:00." The remaining sections on the form included: Location of event: Resident Room was checked; Type of Event: Found on floor/sidewalk was checked; Floor conditions: Dry. The vital signs section was completed. There were no witnesses listed on the form. The form was signed and dated by RN #2, as well as the former administrator and former DON. A notation at the bottom of the page read: "01/7/2013 admitted to (name of hospital) with fx right hip, surgical intervention on 1/5/2013." The DON returned to the conference room at approximately 11:15 a.m. with the remaining pieces of the investigation. She stated, "Here is what I can find." Four witness statements were presented. The following information was obtained from those statements: Statement #1 "I (CNA (certified nursing assistant) #3) was at the desk and the alarm was on. The alarm went off a few times. At about 4:30 p.m. (names of staff) went outside for break. As we were coming in from break (Name of RN #2) met us at the dining room door and said Who got up (last name of Resident #8). His alarm is unhooked (sic). He in (sic) his room on the floor. When we got to (name of Resident #8) room, (names of CNA #4 and #5) was (sic) there. (Name of Resident #8) was on the floor beside the sink. Check him out, did Vit. (vital signs) He seem (sic) to be OK. (Names of CNA #4 and #5) got him up and out him in his chair. From there we discuss (sic) about the alarm. We then push (sic) the resident to the dining room for supper. I (CNA #3) was feeding (name of another resident). (Name of CNA no longer employed at the facility) came in the dining to check on the feeder (sic). (Name of Resident #8) was not eating and sitting in his chair sweating...(Name of CNA no longer employed at the facility) said I'm taking (Name of Resident #8) down to his room...put a gown on him, put him to bed and check him out. Something is wrong...(Name of CNA no longer employed at the facility) ask RN #2 to to come and look at his (Resident #8) hip and at lease (sic) send him out for an xray. (Name of RN no longer employed at the facility) said this happen (sic) all the time its (sic) not a big deal...I (CNA #3) said to (Name of RN #2) I will stay here with your cart while you go check (name of Resident #8) RN #2 said No I'll lock up my cart and nobody will get med (medicine) tonight. Just more paperwork for me to do...(Name of RN #2) came back to the dining room and told us that he was sending him (Resident #8) out. (Name of CNA no longer employed at facility) and I left at that time (6:43 p.m.)." Statement #2 "I (CNA who is no longer employed at the facility) looked over and saw (Name of Resident #8) sitting on the floor with his leg crossed. His chair was in front of the door with his alarm unplugged. I waived down (Name of CNA #4) to come down and look and to get a nurse. He found (Name of RN #2) and I went on to help another patient. I found (Name of Resident #8) at approximately 4:20 p.m. During dinner he pushed away food and looked as if he was in pain. I asked him if he was okay and asked (Name of RN no longer employed at the facility) to assess (Name of Resident #8). She explained that it was (Name of RN #2) responsibility. I then took (Name of Resident #8) by wheelchair to (Name of RN #2) I was persistent to have (Name of Resident #8) checked over and I was asked to put him to bed in a gown. (Name of RN #2) came down to (room number) at 6:50 p.m. to render care." Statement #3 and Statement #4 were typed and on the same paper titled: "Investigation on incident involving (Name of Resident #8) on Friday, January 4." Statement #3 "1/07/2013 Phone conversation with (Name of CNA #4) at 1030 a.m. According to (Name of CNA #4), (Name of RN #2) assessed resident prior to (Name of CNA #4 and CNA #5) transferring resident in to the wc (wheelchair). (Name of CNA #4) stated that (Name of Resident #8) was sitting on his buttocks when he entered the room. With questioning in regards to the alarm cord, (Name of CNA #4) stated that the cord was disconnected from the blue box. Stated he was not aware of any time in which (Name of Resident #8) has been able to disconnect the cord from the alarm box. Upon questioning he stated that the only way that he knew that the resident may have been able to get up was to use the sink for leverage." Statement #4 "1/07/2013 @1038 Phone Conversation with (Name of CNA #5) Became involved because someone flagged her down and stated that resident was in the floor. When she entered the room (Name of CNA # 4) and (Name of RN #2) were already in the room. (Name of CNA #5) stated that resident was sitting on his buttocks with his left leg extended in front of him and his right leg bent underneath (like Indian style). Stated the nurse ask (sic) them to assess resident. (CNA #5) stated that she straightened (Name of Resident #8) right leg. Denies that he verbalized any complaint of pain at that time.. They assessed resident sitting up to see if leg was disproportionate to the other. When asked did they lay him down to look at (sic) she stated no. Routine 2 person transfer, resident did not have any complaints of pain during transfer or when placed in the wheelchair. Stated that it was approximately 30 minutes later that he began to complain of pain. When asked about the alarm she states that resident does not bother the alarm when it is behind him. (Name of CNA #5) states that she feels that resident can push himself up out of the chair using the arms of the chair. But she stated she has never seen him take a step." No interviews from the CNA assigned to Resident #8 were presented. After reviewing the above written statements this surveyor spoke with the DON. The DON was asked if there were any outcomes based on the written statements and what the final determination had been regarding the fall. The DON stated, "I gave you what I have...this was before I got here, I came in July." The DON was asked if all employees named in the written statements were still employed at the facility. She stated, "No." The employees remaining at the facility were, RN #2, CNA #3, CNA #4 and CNA #5. This surveyor requested to speak with the employees who still worked at the facility. RN #2 came to the conference room to speak with this surveyor on 12/10/2013 at approximately 3:40 p.m. He was asked if he recalled the incident that had occurred with Resident #8 on 01/04/2013 which resulted in a hip fracture. He stated, "Yes, I remember...He had been out at the nurse's station...his alarm had gone off, it goes off like ten times a day...he is a wanderer...I guess he went back to his room and when he fell the alarm wasn't hooked up so it didn't go off...I perused the staff that were out at the smoke shack and said you know, "Hey who's taking care of (Last name of Resident #8)...We all talked about it later I don't know how his alarm got undone...he couldn't reach it...his daughter was here I don't know if maybe she disconnected it or not...On initial assessment he had no injury." RN #2 was asked about the written statement which indicated that he had said, "I'll lock up my cart and nobody will get med tonight...just more paperwork for me to do." He stated, "I don't know if I said that...if I did I wasn't serious." He further stated, "Is it our responsibility that the alarm was loose?" CNA #3 was interviewed at approximately 4:00 p.m. on 12/10/2013. She was asked of she remembered the incident. She read through her witness statement and stated, "Yes, I remember it...I wrote that up because (Name of CNA no longer employed at facility) was so upset...she called the DON at home because the nurses would not check on him when he was not eating and sweating in the dining room..." CNA #3 was asked if she had been taking care or Resident #8 on that shift. She stated, "No, (Name of another CNA) was...he no longer works here either." CNA was asked to describe the incident. She stated, "We all left for break, Resident #8 was at the nurse's station, he kept releasing his seatbelt and making the alarm go off...we were gone about 20 minutes...He (Resident #8) can't self propel himself in the wheelchair and park himself in his room...Somebody took him down there." CNA #3 was asked who pushed Resident #8 to his room. She stated, "I don't want to say." She was asked if she suspected that she knew who it was. She nodded her head up and down indicating yes and stated, "Yes, but I don't want to say." She continued, "(Name of RN #2) met us at the door, he was upset." CNA #2 was asked if Resident #8's daughter was in the facility at that time. She stated, "No...somebody had to take him to his room...everything seemed to be OK, we did VS, asked him if he was in pain..straightened out his legs and then put him back in the chair with his lap belt back in place... when he got to the dining room and the tray was set down, he was squirming and sweating...that's when (Name of RN no longer employed at the facility) came in...she was asked to look at him and she said. 'Not my patient, find his nurse.' His nurse (RN #2) was in the kitchen getting applesauce and stuff for his med pass... (Name of CNA no longer employed at the facility) took him to his room and put him in the bed...She came back and said 'Something is wrong with his right hip.' She went to get (Name of RN #2) and he said, 'Bunch of paperwork.' He went and checked him and came back and said he was sending him out." CNA #3 was asked if the Resident #8 could have disconnected his own alarm. She stated, "He couldn't have unplugged it...he has one arm in an immobilizer, he couldn't reach it." CNA #3 was asked if the cord had been loose. She stated, "It wasn't loose...they don't come loose and fall out...it's like a telephone cord, you have to push a place on it to release it...if something happens to the hook we have taped them...his wasn't taped and it worked fine when we plugged it back in...somebody unplugged it." CNA #4 was interviewed on 12/10/2013 at approximately 5:00 p.m. He was asked if he remembered the incident. He stated, "I don' remember who found him...I remember that (Name of CNA #5) and I transferred him back into his chair after his vital signs were taken. (Name of RN #2) was in the room...we speculated that he may have grabbed hold of the sink to stand up...he wouldn't have been able to unplug the alarm. CNA #4 was asked if Resident #8 could have taken himself to his room. He stated, "No, that would be too far for him." CNA #4 was asked if Resident #8's daughter was at the facility. He stated, "No." CNA #5 was interviewed on 12/10/2013 at approximately 5:10 p.m. She stated, "I was called to the room by (Names of RN #2 and CNA #4), (Name of CNA no longer employed at the facility and was assigned to Resident #8) was at dinner...We got his vital signs, (Name of RN #2) checked him over and we put him in his chair." CNA #5 was asked if Resident #8 could disconnect the alarm cord. She stated, "He can't reach that." CNA #5 was asked if Resident #8 could take himself back to his room. She stated, "He is capable of getting down the hall but he doesn't know which room is his...he goes into other resident rooms sometimes...it's not likely that he would end up in his own room...I reset his alarm twice when he was at the nurse's station...it was fine then." The facility policy titled "Abuse Prohibition Identification Investigation Protection/Reporting Response was reviewed following the interviews. According to the policy "An investigation by the administrator or DON MUST be imitated within 24 hours of their knowledge of the alleged incident. This investigation includes interviewing the resident involved, all staff involved (directly or indirectly), any family involved, other residents involved and any visitors involved. The Administrator will document a summary of all interviews." An end of the day meeting was held with the administrator, DON and the regional DON on 12/10/2013 at approximately 5:25 p.m. The above information was shared with the administrative team. No further information was provided from the administrative team at that time. On 12/11/2013 at approximately 10:00 a.m., this surveyor spoke with the DON regarding the incident. She stated, "I wasn't here at the time...I don't know what happened or how the alarm got unhooked...I don't have any other information." An end of the day meeting was held with the DON and the administrator on 12/11/2013 at approximately 3:40 p.m. The DON was asked what the process was when a staff person went on break, specifically who took care of their residents. The DON stated, "When someone leaves the unit they report off to another CNA or a nurse...I can't tell you who's responsibility it was to watch (Name of Resident #8) when his CNA went outside...I would have to pull all the assignments and try to figure it out." The DON agreed that the only person who could answer that question was the CNA who is no longer employed at the facility. No further information was obtained prior to the exit conference on 12/11/2013. 2. Resident # 4 was initially admitted to the facility 2/21/11 with a readmitted [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a significant change assessment dated [DATE]. Resident # 7 was coded as having moderate impairment in cognition. The clinical record was reviewed 12/9/13 at approximately 2:35 p.m. The current POS (physician order [REDACTED]." A review of the care plan for falls included interventions of "Fall mat to bedside." On 12 9/13 at approximately 4:45 p.m. Resident # 4 was observed in bed completely covered. There was a fall mat on the floor at the bedside which was the "wall" side of the bed. There was no fall mat on the floor to the other side of the bed. On 12/9/13 at approximately 4:50 p.m. the unit manager, licensed practical nurse (LPN) # 1 and the DON director of nursing) were in their office. This surveyor asked about only one fall mat for resident # 4. LPN # 1 stated "I think the people with fall mats only have one to one side of the bed." The DON stated "Well, that's my fault. I should have gone back and made sure everybody with a fall mat had one on each side of the bed. When I first started this job, the majority of residents had one side of their bed up against the wall. I saw that as a restraint and contacted the POA's (power of attorney) and RP's (responsible party) to get all the beds moved away from the wall. I didn't go back and look at that and make sure there was a fall mat to each side." During a meeting on 12/11/13 at approximately 4:00 with the administrator, DON, and regional nurse consultant the DON stated "I went back and assessed everyone with a fall mat and they all now have one on each side of the bed."

Based on observation, resident interview, family interview, staff interview and clinical record review, the facility staff failed to ensure four of 13 resident beds were equipped with properly fitting mattresses to prevent accident and injuries. Resident's #106, 110, 111 and 112 bed mattress was shorter than the bed frame. The findings include: 1. Resident #106 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/3/14 was a quarterly assessment. The resident was assessed with [REDACTED]. Resident #106 was assessed as 3/3 (extensive assist needing the aide of two persons for transfers and bed mobility). On 1/28/14 at approximately 12:50 p.m. during initial tour with the marketing director, other staff # 2 (OS #2), Resident #106's mattress was observed. The mattress was approximately 14 inches from the footboard of the bed. OS #2 was asked why the mattress was shorter than the bed frame. OS #2 stated, "I don't know I have to get someone to come and take a look at it." On 1/28/14 at 1:30 p.m. OS #2 stated to this Surveyor, "The mattress has never been an issue, no one has ever mentioned that it was like that but it has been corrected now." On 1/29/14 at approximately 9:10 a.m., the unit manager, who was a licensed practical nurse (LPN) #1 was interviewed regarding the mattress on Resident #106's bed and the length of time the mattress was on the bed. LPN #1 stated, I am not sure why it was like that or how long it was on the bed but I will find out for you." LPN #1 was asked who changed the resident's bed. LPN #1 stated, "the CNAs (certified nursing assistants)." LPN #1 was asked if the CNAs made anyone aware that the mattress was shorter than the bed frame. LPN #1 stated, "I am not sure but I can see where there would be a concern because of the space and the metal in-between the bed frames." On 1/29/14 at approximately 9:20 a.m., the environmental services director, other staff #1 (OS #1) was interviewed regarding the resident's mattress being shorter than the bed frame. OS #1 stated, "We got in new beds and the mattresses were shorter than the beds. I went through yesterday and changed all the ones that were short, I changed (Residents #106, 110, 111, and 112 named), beds." OS #1 was asked if the mattresses were noticed as being shorter than the bed frame prior to 1/28/14, during initial tour, OS #1 stated, "No, I should have paid more attention but I didn't. Housekeeping deep clean the rooms daily." When asked what "deep cleaning" entailed, OS #1 stated, "We flip the mattresses and wipe down the underside and the metal part of the bed frame." OS #1 was asked how often this was done OS #1 stated, "everyday but different rooms are assigned; we do two rooms a day." A copy of the deep cleaning schedule was requested. On 1/29/14 at approximately 9:35 a.m., the CNA, who will be identified as CNA #1, that was caring for Resident #106 was interviewed regarding the improper fitting mattress on the resident's bed. CNA #1 stated, "I never paid much attention to the mattress being short; there were several like that I thought that was how it was supposed to be." CNA #1 was asked if Resident #106 was able to position or reposition herself in bed, CNA #1 stated, "No, we have to position her, she does not move herself." On 1/29/14 at approximately 9:37 a.m., OS #1 presented to this Surveyor a copy of the "Deep Cleaning Schedule." The schedule evidenced that resident #106's room was deep cleaned on 1/2/14, Resident #110's room was deep cleaned on 1/10/14, Resident #111's room was deep cleaned on 1/12/14 and Resident #112's room was deep cleaned on 1/13/14. On 1/29/14 at approximately 9:40 a.m., the administrator was made aware of the above findings. 2. Resident #110 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/13 was a quarterly assessment. The resident was assessed as a 12, able to make decisions. The resident was assessed as a 3/3, extensive assist with the aide of two people for transfers and bed mobility. On 1/29/14 at approximately 1:00 p.m., Resident #110 was observed in his room, his wife was at his bedside assisting with mouth care. Due to the resident's inability to communicate effectively, the resident's wife was interviewed regarding the mattress being shorter than the bed frame. Resident #110's wife stated, "It's been that way for about a year. I used the space to put my coat and other stuff when I would visit. I kind of used it as a storage space. I noticed today the space is not there." Resident #110's wife felt the mattress and stated, "It feels a whole lot better." She then stated to Resident #110, "Honey, does it sleep better?" Resident #110 stated, "Yeah, a lot better but I can sleep on anything I was in the Army." Resident #110's wife was asked if the resident was able to position/reposition himself in bed. Resident #110's wife stated, "No, staff assist him with moving and positioning if he moves staff have to assist him back to the right position." 3. Resident #111 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/14 was a quarterly assessment. The resident was assessed as a 9 for cognitive skills limited decision=making skills. The resident was assessed as a 3/3, extensive assist with the aide of two people for transfers and bed mobility. On 1/29/14 at approximately 1:10 p.m., Resident #111's bed was observed with a properly fitting mattress on the bed. Resident #111 was in bed with his eyed closed and not able to be interviewed at this time. During the interview with OS #1 on 1/29/14 at 9:20 a.m., OS #1 stated that Resident #111's mattress was changed to fit the bed frame. 4. Resident #112 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/1/13 was a quarterly assessment. The resident was assessed as a 14 for cognitive skills, independent in decision-making skills. The resident was assessed as a 3/3 extensive assist with the aide of two people for transfers and bed mobility. On 1/29/14 at approximately 1:20 p.m., Resident #112 was interviewed regarding the mattress being shorter than the bed frame. Resident #112 stated "It's been like that for as long as I've been here, they changed it and it feels better." When asked how long Resident #112 had been at the facility, Resident #112 stated, "I've been here about five (5) years." When asked if he moved around the bed, Resident #112 stated, "Yes frequently staff has to pull me up in the bed." Resident #112 was asked if he was able to move himself in bed if he slid down too far, Resident #112 stated, "No." On 1/29/14 at approximately 4:00 p.m., the administrator, director of nursing and the regional director of operations were made aware of the above findings.