Every finding on record at Heritage Plaza Nursing Center

Based on interview and record review, the facility failed to obtain physician orders for the resident's immediate care for 2 (Resident #45 and Resident #46) of 5 residents reviewed for admission physician orders. 1.The facility failed to obtain physician orders for the immediate care of Resident #45's surgical wounds, diet, and isolation status. 2.The facility failed to obtain physician orders for the immediate care of Resident #46's surgical wound, pressure wounds, diet, and isolation status. These failures could affect residents who were admitted or readmitted to the facility by placing them at risk for not receiving the appropriate care, medication, and treatment services.Findings included: 1.Record review of an undated face sheet revealed Resident #45 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of End Stage Renal Disease (Stage 5 chronic kidney disease, occurs when the kidneys lose 85% to 90% of their function, meaning they can no longer filter waste and fluids), Diabetes type II (a chronic metabolic condition where the body resists insulin or cannot produce enough of it), heart failure (heart muscle doesn't pump blood as well as it should to meet your body's needs), and recent amputation (surgical removal) of toes 3, 4, and 5 on the left foot. Record reviews of the electronic health record on 05/31/2026 revealed Resident #45 admitted on [DATE] at 10:17 a.m. The EHR revealed no admission assessment, no pain assessment, no skin assessment was completed on admission for Resident #45. Resident #45 had no orders for wound care for his surgical wound from 05/28/2026 until 06/01/2026. He had no orders for contact isolation for suspected shingles from 05/28/2026 until 05/31/2026. He had no diet order from 05/28/2026 until 05/29/2026. Record review of the MD orders for Resident #45 revealed the following:05/29/2026- Liberal Renal Diet.05/29/2026- Atorvastatin 40mg each night05/29/2026- calcitriol 0.25 mg three times a week05/29/2026- furosemide 80mg twice daily05/29/2026- midodrine 5mg twice daily05/29/2026- sertraline 25mg daily05/29/2026- sevelamer carbohydrate 800mg three times a day with food05/29/2026- valacyclovir 500mg daily.05/31/2026-Enhanced Barrier Precaution (EBP) every shift for wounds and dialysis.05/31/2026-Isolation Contact every shift for suspected shingles each shift.06/01/2026-Monitor area to 4th digit on Right foot on day shift. Cleanse with normal saline or wound cleanser, pat dry and leave open to air once daily.06/01/2026- Monitor area to top of 4th digit on left foot on day shift. Cleanse with normal saline or wound cleanser, pat dry and leave open to air once daily. Record review Resident #45's discharge orders from the hospital dated 05/28/2026 included orders for atorvastatin, calcitriol, furosemide, Humalog, Lantus, midodrine, sertraline, sevelamer carbonate, and valacyclovir. Record review of Resident #45's MAR/TAR for May 2026 indicated Resident #45 did not receive any medications on 05/28/2026 and no treatment to his surgical wound until 05/31/2026. During an interview on 05/31/2026 at 10:30 a.m., Resident #45 stated that he had concerns because for the first day and a half of him being in the facility, he got no medications and no treatments to his surgical wound. He stated when he asked the nurses about the medications they told him no medications had arrived for him from the pharmacy. He stated he was giving them until the Director came in on Monday morning to figure something out or he was going to leave. Resident #45 stated no one wore gowns or masks when assisting him with care. He said the CNA wore gloves when she emptied his urinal. He stated he knew he had shingles in the hospital but thought maybe it was resolved since no one was wearing the protective gear. 2. Record review of an undated face sheet revealed Resident #46 was a [AGE] year-old female that admitted on [DATE] with the diagnoses of End Stage Renal Disease (Stage 5 chronic kidney disease, occurs when the kidneys lose 85% to 90% of their function, meaning they can no longer filter waste and fluids), Diabetes type II (a chronic metabolic condition where the body resists insulin or cannot produce enough of it), heart failure (heart muscle doesn't pump blood as well as it should to meet your body's needs), and recent amputation (surgical removal) of 2nd digit on right foot. Record reviews of the electronic health record on 05/31/2026 revealed Resident #46 admitted on [DATE] at 3:17 p.m. The EHR revealed no admission assessment, no pain assessment, no skin assessment was completed on admission for Resident #46. Resident #46 had no orders for wound care for her surgical wound or her pressure wounds from 05/29/2026 until 05/31/2026. She had no orders for EBP from 05/29/2026 until 05/31/2026. She had no diet order from 05/28/2026 until 05/29/2026. Record review of the MD orders for May 2026 for Resident #46 revealed the following:05/30/2026-Amlodipine Besylate 5mg one time daily05/30/2026 Atorvastatin 20mg at bedtime05/31/2026- Renal Liberal Diet05/31/2026-Blood Glucose check twice daily05/30/2026-Amlodipine Besylate 5mg one time daily05/30/2026 Atorvastatin 20mg at bedtime05/31/2026-Carbamazepine 200mg twice daily05/31/2026-Levothyroxine 75mcg once daily05/31/2026-Metoprolol Succinate 50mg twice daily05/31/2026-Vitamin B Complex one time daily05/31/2026-Folic Acid 0.4 mg once daily05/31/2026-Vitamin C 500mg once daily05/31/2026-Restora once daily05/31/2026-Doxycyline 50mg twice daily for 14 days05/31/2026-Eliquis 2.5mg twice daily05/31/2026- Enhanced barrier precautions r/t vascular access05/31/2026-Cleanse distal wound on right buttocks on day shift05/31/2026-Cleanse proximal wound on right buttock on day shift05/31/2026-Cleanse surgical site to right 2nd digit amputation on foot. Record review Resident #46's discharge orders from the hospital dated 05/29/2026 included orders for Amlodipine Besylate, Atorvastatin, Carbamazepine, Levothyroxine, Metoprolol Succinate, Vitamin B Complex, Folic Acid, Vitamin C, Restora, Doxycyline, and Eliquis. Record review of Resident #46's MAR/TAR for May 2026 indicated Resident #46 did not receive any medications on 05/29/2026 and no treatment to her surgical wound and pressure wounds until 05/31/2026. During an interview on 06/01/2026 at 10:45 a.m., LVN A stated it was the responsibility of the admitting nurse to ensure that all admission orders were entered and clarified by the physician. She stated it was the responsibility of the admitting nurse administer the first dose of medications due on their shift, to do the admission assessment, start the baseline care plan, and do as many of the assessments like pain and skin, as possible. What was not done on the admitting shift is to be done on the next shift. She stated not following these time guidelines can cause the newly admitted residents to miss doses of medication and treatments needed to prevent decline in skin integrity. During an interview on 06/02/2026 at 11:00 a.m., the DON stated the admission process for new residents was that the admitting nurse completes the admission assessment, enter all MD orders from the hospital discharge information, start the baseline care plan, clarify all orders with the physician and administer the initial dose of medications ordered on their shift. The DON stated it was the expectation that documentation would include vital signs, a full body assessment to include pain and skin issues that need to be addressed. She stated she was aware she had a nurse that failed to handle the admissions of Resident #45 and Resident #46 appropriately by not entering medications into the EHR, not completing the admission assessment that includes a skin assessment, not completing a pain assessment, not ensuring the residents had diet orders and isolation orders. She stated the oncoming shift failed to follow up and ensured the residents had orders and assessments completed. The DON stated not ensuring initial MD orders are in the EHR for all residents and not ensuring their assessments are completed can cause delay in care for the residents. She stated the department head nurses always check the orders and assessments for completion and accuracy on the first business day after the resident admits. During an interview on 06/02/2026 at 12:15 p.m., the Administrator stated it was the responsibility of the admitting nurse to ensure that the resident had all orders in the HER and that the pharmacy was aware of the orders and was sending the medication. She stated it was the admitting nurse's responsibility to complete the admission assessment and notify the MD of the arrival of the resident and clarify any orders needed after assessing the resident. She stated she was unaware this process was not being followed. She stated it was the responsibility of the DON and administrative nurses to ensure the residents have all the orders they need and all assessments are completed correctly. She stated the failure to do so could lead to the residents feeling ignored and unimportant. An undated policy titled 'Admitting a Resident' indicated the following: .6. Assist resident into bed. Observe carefully for any open or draining areas, dressings, rashes, bruises or reddened areas and report these to the charge nurse.7. The licensed nurse interviews resident/family member and initiates the admission Nursing data Collection.The drug regimen review is to be completed.12. The licensed nurse notifies the attending physician of his/her arrival and orders.13. Complete and record resident's height, weight, temperature, blood pressure, pulse and respirations on the admission Nursing Assessment and other daily documentation per policy. This should be entered into the Vital sign module of EHR so the data will flow to the admission data collection21. Document activities in the Resident medical record as they are triggered in the data collection/admissions tab.

Based on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #2, #5, #29, and #6) of 12 residents reviewed for care plans.1. The facility failed to develop a care plan for Resident #2's use of Eliquis (an anticoagulant medication that thins the blood and places the resident at an increased risk of bleeding and bruising more easily).2. The facility failed to update Resident #5's care plan to include he often refused to take his insulin or full dosage of insulin as prescribed by his physician.3. The facility failed to develop a care plan for Resident #29's use of Paroxetine (antidepressant medication used to treat depression (persistent sadness)), Lorazepam (antianxiety medication used to treat anxiety (feelings of worry)), Clopidogrel (antiplatelet medication that stops platelet cells from sticking together in the blood and could thin the blood and place the resident at an increased risk of bleeding and bruising), and the use of Nitrofurantoin (antibiotic used to treat and prevent urinary tract infections).4.The facility failed to develop a care plan for Resident #6's hospice status.These failures could place residents at risk of not having their individualized needs met and a decline in their quality of care and life. Findings included: 1. Record review of Resident #2's face sheet dated 6/01/26 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses including Parkinson's (disease that causes movement problems), fracture of left femur (upper leg), dementia (decline in cognitive abilities such as memory, reasoning, language, and behaviors that interfere with ADLs), atrial flutter (abnormal heart rhythm where the upper portion of the heart beats too quickly), and hypertension (high blood pressure). Record review of Resident #2's annual MDS assessment dated [DATE] indicated he was sometimes understood and sometimes understood others. The MDS indicated he had a BIMS score of 11, which indicated he had moderate cognitive impairment. The MDS indicated Resident #2 had fluctuating inattention and disorganized thinking. The MDS indicated Resident #2 had physical and verbal behavioral symptoms. The MDS indicated Resident #2 was dependent on staff assistance for most ADLs. The MDS indicated Resident #2 had a history of falls. The MDS indicated Resident #2 was taking an anticoagulant. Record review of Resident #2's Physician Orders dated 6/01/26-6/30/26 revealed an order for Eliquis 5 mg tablet one tablet by mouth twice a day for surgical incision with a start date of 5/13/26. Record review of Resident #2's care plan dated 6/01/26 did not show a care plan for his use of an anticoagulant, Eliquis. During an observation and interview on 5/31/26 at 11:14, Resident #2 was observed to have multiple bruises to his upper and lower right arm. Resident #2 said he fell and busted his hip and was getting therapy and it was going very well. 2. Record review of Resident #5's face sheet dated 6/02/26 indicated he was [AGE] years old and admitted to the facility on [DATE] initially and readmitted [DATE]. Resident #5 had diagnoses including Diabetes mellitus and Schizoaffective disorder, bipolar type (mental health disorder that combined symptoms such as hallucinations {sensory experiences that appear real but created by the mind}), delusions (belief something was real with clear evidence that it was not), with a major mood disorder such as depression or bipolar disorder (causes extreme shifts in mood, energy, and activity levels)). Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 15, which indicated he was cognitively intact. The MDS did not indicate Resident #5 had behavioral symptoms or refused care. The MDS indicated he took insulin injections daily. Record review of Resident #5's care plan dated 6/01/26 indicated he had potential for hyperglycemic (high blood sugar)/hypoglycemic (low blood sugar) episodes secondary to diabetes. Resident #5 used insulin. The care plan interventions included administering medications as ordered and monitoring for adverse side effects and insulin injections as ordered by physician. The care plan did not indicate Resident #5 refused to take insulin or refused to take the full dose of insulin as ordered by the physician. Record review of Resident #5's Active Orders Report dated 6/02/26 revealed an order for Lantus (long-acting insulin used to treat diabetes) 30 units injected twice daily, nurse may administer less than prescribed dosage per resident preference with a start date of 6/02/26. There was an order for Novolin R (fast-acting regular insulin used to treat diabetes) per sliding scale before meals and at bedtime with a start date of 11/17/25. Sliding Scale as follows: BS 0-60= call physician BS 0-149= 0 units of insulin BS 150-199= 3 units of insulin BS 200-249= 6 units of insulin BS 250-299= 9 units of insulin BS 300-349= 12 units of insulin BS 350 or greater = 15 units of insulin BS over 400, administer insulin per sliding scale and recheck BS in an hour, if still over 400 then call physician. Record review of Resident #5's Medication Record dated 5/04/26-6/02/26 revealed he did not take his sliding scale Novolin R insulin as ordered for his 7:00 AM dose 9 times, 11:30 AM dose 12 times, 4:30 PM dose 14 times, and 9:00 PM dose 11 times. Resident #5's Medication Record revealed he did not take his Lantus 30 units twice daily as ordered for his 7:00 AM dose 12 times and his 4:30 PM dose 10 times, with only taking a reduced dose or none at all. Record review of Resident #5's Interdisciplinary Progress Notes dated 5/01/26-5/31/26 revealed he refused his insulin on multiple occasions and had said he was afraid he would bottom out. During an observation and interview on 6/01/26 at 11:15 AM, Resident #5 had a BS of 311. The nurse attempted to administer the ordered 12 units of insulin and Resident #5 stated he would take 6 units, but he was not taking 12 units. LVN A administered 6 units of regular insulin to Resident #5. LVN A stated Resident #5 always refused the ordered amount of insulin and dictated how many units he would take. LVN A stated his blood sugar was never in the normal range when she checked it. She stated it was always higher than normal. 3. Record review of Resident #29's face sheet dated 6/01/26 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #29 had diagnoses including Malignant neoplasm of left kidney (abnormal growth of cancerous cells in the kidney), history of urinary tract infection, kidney stones, malignant pleural effusion (abnormal buildup of fluid containing cancerous cells in the space between the lungs and the chest wall), cardiomegaly (enlarged heart), depression (persistent sadness), and altered mental status. Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 15, which indicated she was cognitively intact. The MDS indicated Resident #29 was taking antianxiety, antidepressant, antibiotic, and an antiplatelet. Resident #29 was receiving hospice services (end of life care). Record review of Resident #29's Physician Orders dated 6/01/26-6/30/26 revealed the following orders: Paroxetine 10 mg one tablet by mouth at bedtime for depression with a start date of 3/09/26. Lorazepam 1 mg 1 tablet by mouth twice a day for anxiety/agitation with a start date of 8/29/25. Nitrofurantoin 100 mg by mouth at bedtime for diagnostic with a start date of 8/01/25. Clopidogrel 75 mg 1 tablet by mouth at bedtime for diagnostic with a start date of 8/01/25. Record review of Resident #29's care plan dated 6/01/26 revealed there were no care plans developed for her use of antianxiety, antidepressant, antibiotic, and antiplatelet medications. 4. Record review of an undated face sheet revealed Resident #6 was a [AGE] year-old male admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic lung disease), acute and chronic respiratory failure (acute failure develops suddenly as an emergency, chronic failure builds gradually over time), and diabetes. Record review of Physician's Orders dated 06/01/26 for Resident #6 indicated an order to admit to hospice with a start date of 04/03/26. Record review of a significant change MDS assessment dated [DATE] revealed Resident #6 had a BIMS score of 13 which indicated no cognitive impairment. The MDS indicated Resident #6 received hospice care while he was a resident in the facility. Record review of the care plan revised on 05/11/26 revealed Resident #6 was not care planned for hospice services. During an interview on 06/02/2026 at 11:40 a.m., the MDS Coordinator stated the care plans should include all items that were coded on the MDS. She stated the care plan should be reviewed by the nursing staff to know the individual care instructions for each resident. The MDS Coordinator stated items such as falls, high risk medication usage, hospice services, and diagnoses should be care planned for resident safety. She stated not care planning an important item with the interventions could result in the staff not knowing what is needed for the management of the individual resident condition. She stated Resident #2's anticoagulant medication, Resident #5's refusal of insulin, Resident #29's psych medications, and Resident #6's hospice status should have all been care planned. During an interview on 06/02/2026 at 1:00 p.m., the DON stated it was the responsibility of the MDS nurse to create the comprehensive care plan and all nurses' responsibility to ensure that acute changes be updated on the care plan. She stated all major diagnoses, conditions, medications, and falls should be care planned with interventions to alert the staff of the potential of these situations recurring and to give instructions on what to do in those cases. The DON stated she did not feel care planning had a negative impact on the residents. During an interview on 06/02/2026 at 1:30 p.m., the Administrator stated she expected the MDS nurse and administrative nurses to ensure the care plans were complete and accurate for each individual. She stated care plans were meant to be a blueprint to individual resident care and were important to individualized care. Record review of the Care Plans, Comprehensive Person-Centered policy, dated April 2021, reflected A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.the comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;.and which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.the interdisciplinary team reviews and updates the care plan. at least quarterly.

Based on interviews and record review, the facility failed to ensure dialysis services were provided consistently with professional standards of practice for 1 of 3 resident reviewed for dialysis services. (Residents #7)The facility failed to document Resident #7's Post (after) Dialysis assessment on his Dialysis Communication (Pre/Post-before/after) Forms on 5/04/26, 5/08/26, 5/13/26, 5/18/26 and 5/20/26.This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.Findings included:Record review of Resident #7's face sheet dated 6/01/26 indicated he was [AGE] years old and admitted to the facility on [DATE] originally and re-admitted [DATE]. Resident #7 had diagnoses including end stage renal disease (condition where the kidney reaches advanced state of loss of function), hypertensive (high blood pressure) heart disease with chronic kidney disease, heart failure and diabetes mellitus (high blood sugar).Record review of Resident #7's Active Orders Report dated 6/02/26 indicated he had an order dated 12/05/25 for Dialysis on day shift, monitor shunt/graft/fistula for signs/symptoms of infection and adequate circulation, right chest Permacath (long-term tunneled dialysis catheter used to access the blood stream for dialysis) and left arm shunt (surgically created high-flow access point required to cycle a patient's blood during hemodialysis (life-sustaining treatment to filter waste and excess fluid from the blood due to kidney failure)), Hemodialysis every M-W-F . must be weighed before and after treatment and communicated with office staff due to geri-chair (specialized, highly padded reclining chair on wheels).Record review of Resident #7's MDS assessment dated [DATE] indicated he had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS indicated Resident #7 had no behaviors or refusal of care. The MDS indicated Resident #7 received dialysis while a resident at the facility.Record review of Resident #7's Plan of Care dated 6/01/26 indicated he had ESRD (End stage renal{kidney}disease) and was at risk for complications of renal failure and was receiving dialysis M-W-F. The interventions included: observe for edema, warmth and color of extremities, shortness of breath, vital signs daily, report abnormalities to the physician with follow up as indicated.Record review of Resident #7's Dialysis Communication (Pre/Post) Forms for the month of May 2026, revealed he had incomplete dialysis communication forms for the following dates: 5/04/26, 5/08/26, 5/13/26, 5/18/26, and 5/20/26. The Dialysis Communication Forms revealed there was no documentation in the Post Dialysis Report section, to be completed by the Nursing Staff upon the resident's return to the facility, which included vital signs (blood pressure, pulse, respirations, and temperature), whether there was any new orders, and there was no assessment of the dialysis access site for swelling, redness, signs of infection, and whether reinforcement of the dressing was needed. Resident #7's Dialysis Communication (Pre/Post) Forms indicated RN A had completed the Pre Dialysis Report section on 5/04/26, 5/08/26, 5/13/26 and 5/18/26.During an interview on 06/02/2026 at 12:44 PM, RN A said she had worked at the facility for about a month. RN A said before a resident was sent to dialysis, she would get a set of vital signs, assess the resident, fill out the top portion of the Dialysis Communication Form and send it to dialysis with the resident. RN A said Resident #7 went to dialysis by the ambulance service and she sent the form and his lunch with the ambulance service. RN A said when the resident comes back from dialysis, they get the form, then transfer the dialysis unit's part to the Dialysis Communication Form. RN A said then she checks the resident's vital signs, assesses the dialysis access site for bleeding and documents it on the bottom portion of the Dialysis Communication Form. RN A said there had been a few times Resident #7 had come back the facility after her shift ended, but the Dialysis Communication Form and assessment should be completed by the nurse on shift when the resident came back from dialysis. RN A said the Dialysis Communication Form was a tool to communicate between the dialysis center and the facility and to make sure the resident was in stable condition. RN A said the nurse on duty would be responsible for ensuring the Dialysis Communication Form was completed and the resident was assessed when he came back from dialysis. RN A said if the resident was not assessed after dialysis, he may be not feeling well after dialysis, and they could miss something that could be life harming. During an interview on 06/02/2026 at 12:54 PM, the ADON said the nurse was supposed to open the dialysis form and send with the resident to dialysis. The ADON said then the dialysis center fills in their part and sends the form back to the facility. The ADON said the Dialysis Communication Form then would be put in the scan box to be scanned into the EHR and then the receiving nurse fills in section 3 (bottom portion) to include assessing the access site dressing and a set of vital signs. The ADON said the Dialysis Communication Form was to let the dialysis center know if there have been any changes and for the dialysis center to let the facility know if there had been any changes or anything out of the norm. The ADON said the nurses should be completing the Dialysis Communication Forms and the administration team should be auditing to ensure they were being completed. The ADON said Resident #7 sometimes came back during or after shift change. The ADON said there could be a delay in care of a condition they may not be aware of, if the nurse was not assessing/checking the dialysis access site and vital signs after dialysis. During an interview on 06/02/2026 at 1:27 PM, the DON said the top portion of the Dialysis Communication Form was filled out and printed and sent with the resident, then the dialysis unit completed their portion, and then the nurse completed the portion after dialysis when the resident returned. The DON said the nurse on duty was responsible for completing the form. The DON said the purpose of the form was to monitor their vital signs and make sure the resident was stable when they returned from dialysis and not having any adverse effects from dialysis. The DON said if the resident was not being assessed after dialysis, they could have a negative outcome after returning from dialysis and they may not know it.During an interview on 6/02/26 at 1:27 PM, the ADM said she would expect staff to complete the Dialysis Communication forms if that was what was required. The ADM said she was not clinical and did not know what the adverse effect for the resident would be for not completing the Dialysis Communication Form.Record review of the facility's policy dated revised February 12, 2020 and titled Dialysis-Hemodialysis - Guidelines for Care of the Dialysis Resident's Competency, Shunt Care, indicated . Staff would ensure that residents who require dialysis receive such services consistent with standards of practice . The dialysis staff and the community staff will participate in ongoing communication by completing the dialysis collection form as follows . b. Pre-Dialysis: Section A to be completed by the sending community licensed nurse and to accompany patient to the dialysis center . c. Post Dialysis: Community nurse to complete Section B with dialysis center information. Community nurse to assess and complete Section C . d. Place document in the appropriate section of the medical record .

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 6 residents (Resident #2) reviewed for unnecessary medications.The facility failed to ensure Resident #2 had monitoring for an anticoagulant medication, Eliquis (an anticoagulant medication thins the blood and could cause serious, potentially fatal bleeding and bruising more easily).The facility failed to ensure Resident #2's order for Eliquis had an appropriate diagnosis.These failures could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the use of medicines).Findings included:Record review of Resident #2's face sheet dated 6/01/26 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses including Parkinson's (disease that causes movement problems), fracture of left femur (upper leg), dementia (decline in cognitive abilities such as memory, reasoning, language, and behaviors that interfere with ADLs), atrial flutter (abnormal heart rhythm where the upper portion of the heart beats too quickly), and hypertension (high blood pressure).Record review of Resident #2's annual MDS assessment dated [DATE] indicated he was sometimes understood and sometimes understood others. The MDS indicated he had a BIMS score of 11, which indicated he had moderate cognitive impairment. The MDS indicated Resident #2 had fluctuating inattention and disorganized thinking. The MDS indicated Resident #2 had a history of falls. The MDS indicated Resident #2 was taking an anticoagulant.Record review of Resident #2's Physician Orders dated 6/01/26-6/30/26 revealed an order for Eliquis 5 mg tablet one tablet by mouth twice a day for surgical incision with a start date of 5/13/26.Record review of Resident #2's care plan dated 6/01/26 did not show a care plan for his use of an anticoagulant, Eliquis.Record review of Resident #2's MAR dated 5/03/26-6/01/26 indicated Eliquis 5 mg, give 1 tablet by mouth twice daily for surgical incision with a start date of 5/13/26. Resident #2 received twice daily doses as ordered. The MAR did not indicate assessment or monitoring for side effects of Eliquis to include signs or symptoms of bleeding or bruising.During an observation and interview on 5/31/26 at 11:14, Resident #2 was observed to have multiple bruises to his upper and lower right arm. Resident #2 said he fell and busted his hip and was getting therapy and it was going very well.During an interview on 6/02/26 at 12:54 PM, the ADON said Eliquis should have monitoring in place for bruising and any abnormalities. She said having monitoring in place brought more attention to the resident being on the medication, so they could notify the MD if additional testing may need to be done. The ADON said if staff were not monitoring for adverse effects of Eliquis, there could be internal processes that they may not be aware of. The ADON said their previous EHR software would have automatically added monitoring to the MAR when Eliquis was ordered. The ADON said their current EHR software did not automatically add monitoring to the MAR, and it must have been missed by mistake.During an interview on 6/02/26 at 1:27 PM, the DON said there should be monitoring for bleeding, and it should be documented on the MAR. The DON said for an anticoagulant medication, such as Eliquis, they should be monitoring for bleeding/bruising. The DON said if they were not monitoring for bleeding, the resident could be bleeding, and they would not know it. The DON said it must have been missed because he had just started on it after his fall and went into Atrial Flutter in the hospital. The DON said the indication for use, surgical incision, was not an appropriate diagnosis attached to the order for Eliquis. The DON said Resident #2 did have the diagnosis of Atrial Flutter, which was the reason he was on the medication, and it should be attached to the order for Eliquis. The DON said they could miss something, if they were not monitoring for adverse effects of the medication and would not catch it.During an interview on 6/02/26 at 1:27 PM, the ADM said she would expect the monitoring for an anticoagulant to be in place and care planned if it was supposed to be. The ADM said the resident had the potential to bleed if they had an accident. The ADM said if staff were not monitoring for bleeding and the bleeding was not stopping, depending on the injury, it could cause some serious issues.During an interview on 6/03/26 at 10:20 AM, the Consulting Pharmacist returned surveyor's call from 6/02/26. She said when she did her monthly reviews, she looked for medications including anticoagulants to ensure there was monitoring for bleeding/bruising in place and if the medication had an appropriate diagnosis for the use of the medication. She said the monitoring of the medication would be looking for any adverse reactions or side effects of the medication that could warrant a change in medication or dosage. She said if Resident #2 had started the Eliquis 5/13/26, she has not been back to the facility to do her monthly review for June 2026 yet.Record review of the facility's policy titled, Medication Administration dated 1/2024 indicated . Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices . 1. Medications are administered in accordance with written orders or the prescriber . if a dose seems excessive . or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification . if necessary, the nurse contacts the prescriber for clarification . The policy did not address monitoring for adverse reactions/effects of medication.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 14 (Resident #6, Resident #45) residents reviewed for infection control practices. 1. The facility failed to wear PPE when providing direct care to Resident #6 on EBP. 2. The facility failed to wear PPE when providing direct care to Resident #45 on contact isolation. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.Findings included: 1. Record review of an undated face sheet revealed Resident #6 was a [AGE] year-old male was originally admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic lung disease), acute and chronic respiratory failure (acute failure develops suddenly as an emergency, chronic failure builds gradually over time), and diabetes. Record review of Physician's Orders dated 06/01/26 for Resident #6 indicated an order for tracheostomy (a surgical procedure that creates a small opening in the front of the neck and directly into the windpipe (trachea). A tube is placed into this opening to bypass the nose and mouth, providing a direct airway for breathing) skin care every shift by replacing split dressing with a start date of 02/24/26. There was an order to replace the inner cannular (a removable, tube-like liner that sits inside the outer tracheostomy tube) daily on day shift and as needed with a start date of 02/24/26. There was an order for enhanced barrier precautions every shift for tracheostomy with a start date of 04/23/26. Record review of a significant change MDS assessment dated [DATE] revealed Resident #6 had a BIMS score of 13 which indicated no cognitive impairment. The MDS indicated Resident #6 received tracheostomy care while being a resident in the facility. Record review of the care plan revised on 05/11/26 revealed Resident #6 had enhanced barrier precautions to prevent multidrug-resistant organisms (refers to bacteria or fungi that are resistant to one or more classes of antimicrobial drugs, making an infection they cause highly difficult to treat). There was an intervention for gown and glove use during high-contact resident care activities such as.wound care, and any skin opening requiring a dressing. During an observation on 06/01/26 at 1:00 p.m., RN A provided tracheostomy care, including changing the split dressing, to Resident #6. RN A did not wear a gown during the care. During an interview on 06/01/26 at 1:38 p.m., RN A said Resident #6 was on enhanced barrier precautions due to him having a tracheostomy. She said she was supposed to have worn a gown. She said enhanced barrier precautions were meant to protect the patients with wounds or open areas from infection. 2. Record review of an undated face sheet revealed Resident #45 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of End Stage Renal Disease (Stage 5 chronic kidney disease, occurs when the kidneys lose 85% to 90% of their function, meaning they can no longer filter waste and fluids), Diabetes type II (a chronic metabolic condition where the body resists insulin or cannot produce enough of it), heart failure (heart muscle doesn't pump blood as well as it should to meet your body's needs), and recent amputation (surgical removal) of toes 3, 4, and 5 on the left foot. Record reviews of the electronic health record on 05/31/2026 revealed no admission assessment, no MDS, no baseline care plan, and no comprehensive care plan were completed for Resident #45. Record review of MD orders dated 06/01/2026 revealed Resident #45 had an order for contact isolation related to shingles (a viral infection caused by the varicella-zoster virus). He also had an order for Valtrex 500mg daily for suspected shingles infection dated 05/29/2026. During an observation on 05/31/2026 at 10:30 a.m., CNA B entered Resident #45's room and assisted Resident #45 up to sit on the side of the bed and with the use of a urinal. CNA B failed to wear any PPE while assisting Resident #45. There was no PPE located inside the room, bathroom, or outside the door including gloves. During an interview on 05/31/2026 at 10:45 a.m., CNA B stated she was not aware Resident #45 was on isolation. She stated the electronic health record normally had an alert for all residents on isolation. She stated Resident #45 did not have indications he was on contact isolation or EBP and with no isolation set up in the room or outside the door, she was completely unaware she needed to wear PPE in his room. She stated not knowing this could mean she spread infections to other residents she is caring for, as well as herself and her family. During an interview on 06/02/26 at 12:20 p.m., the DON said she expected staff to know when a resident was on enhanced barrier precautions and the process they should be following. She said she would have expected RN A to have worn a gown along with gloves while providing care to Resident #6. She said she would have expected CNA B to have worn appropriate PPE while providing care to Resident #45. She said it was important to follow enhanced barrier precautions and contact isolation precautions to prevent possible infection control issues. During an interview on 06/02/26 at 12:20 p.m., the Administrator said she would have expected staff to be aware of enhanced barrier precautions and contact isolation and wear appropriate PPE while providing care. She said it was important to wear PPE to keep from transmitting any possible bacteria or infection. Record review of an Enhanced Barrier Precautions facility policy revised in March 2025 indicated, .Many resident in nursing homes are at increased risk of becoming colonized and developing infections with multi-drug resistant organisms.This facility utilizes Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC (Centers for Disease Control) -targeted and epidemiologically important MDROs (multidrug-resistant organisms) when contact precautions do not apply.Indications.Wounds and/or indwelling medical devices.High Contact Resident Care Activities.Device care or use: Central line, Urinary Catheter, feeding tube, tracheostomy.

Based on interview and record review, the facility failed to notify the state mental health authority promptly after a significant change in their mental condition for 1 of 5 residents screened for PASRR (Resident # 37). The facility failed to refer a resident with a newly identified serious mental illness for a PASRR Resident Review following a significant change in status. Resident #37 received a new diagnosis of bipolar disorder on 07/24/2025; however, the facility did not complete a PASRR Level II Resident Review referral (form 1012) until 01/26/2026. This failure could delay the identification of specialized services and support needed to address the residents' mental health needs.Findings included: Record review of an undated face sheet revealed Resident #37 was a [AGE] year-old, female and admitted on [DATE] with diagnoses cerebral infarction (a critical medical emergency that occurs when blood flow to a specific area of the brain is blocked or significantly reduced, preventing brain tissue from receiving essential oxygen and nutrients), seizure disorder (a neurological condition diagnosed when a person experiences two or more unprovoked seizures), and bipolar disorder (a chronic mental health condition characterized by severe shifts in mood, energy, and activity levels). Record review of an annual MDS assessment dated [DATE] indicated Resident #37 had a BIMS score of 15, which indicated no cognitive impairment. Resident #37 was coded as not considered by the state level II PASRR process to have a serious mental illness. Resident #32 required supervision/ set up assistance with for ADLs. Resident #37 had depression, PTSD, and bipolar disorder. Record review of a care plan dated 03/17/2026 indicated Resident #37 had bipolar disorder with potential for mood swings. Record review of Resident #37's PASRR level I screening dated 04/08/2025, completed by the RN case manager at a local hospital, indicated .mental illness .is there evidence or an indicator this is an individual that has a mental illness .No . Record review of Resident #37's physician progress notes dated 07/24/2025 indicated to add the diagnosis of bipolar disorder to Resident #37's health record. Record review of Resident #37's Form 1012 dated 01/26/2026 indicated Resident #37 had a diagnosis of bipolar disorder added to her health record on 07/24/2025. During an interview with the MDS Coordinator on 06/01/2026 at 2:15 p.m., she stated she had not immediately done the Form 1012 to inform PASRR services of the change in Resident #37's diagnosis because she was not aware of the addition to her diagnosis until she prepared to do her MDS in January of 2026. She stated most of the time the IDT discusses new diagnosis in the morning clinical meetings, but she must have been absent because she did not recall the new diagnosis of bipolar disorder for Resident #37 being added. She stated the PASRR reviewers should have been notified within 30 days of the added diagnosis. The MDS Coordinator stated not having Resident #37 screened could have resulted in missed specialized services and support she may have needed for her mental health. During an interview on 06/02/2026 at 11:00 a.m., the DON said she felt like it was discussed in the clinical meeting when the NP wrote the diagnosis of bipolar disorder for Resident #37 and she was unaware the PASRR reviewers were not notified of the change in her diagnosis. She stated it was the responsibility of the MDS nurse to notify PASRR and that not doing so could have prevented Resident #37 from receiving benefits that she may have benefitted from related to mental illness. During an interview on 06/02/2026 at 12:15 p.m., the Administrator stated it was discussed in the clinical meeting when Resident #37 had documentation of having bipolar disorder. She stated the MDS Coordinator should have informed the PASRR reviewers of the change so that appropriate action could be taken to ensure Resident #37 received all the benefits of the PASRR program. PASRR policy was requested on 06/02/2026 at 12:45 p.m. by the Administrator. No policy was received related to PASRR.

Based on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 2 residents reviewed for new admissions (Resident #45) The facility did not complete a baseline care plan or have a baseline care plan meeting with Resident #45 within 48 hours of admission. This failure could place residents at risk of not receiving care and services to meet their needs.Findings included: Record review of an undated face sheet revealed Resident #45 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of End Stage Renal Disease (Stage 5 chronic kidney disease, occurs when the kidneys lose 85% to 90% of their function, meaning they can no longer filter waste and fluids), Diabetes type II (a chronic metabolic condition where the body resists insulin or cannot produce enough of it), heart failure (heart muscle doesn't pump blood as well as it should to meet your body's needs), and recent amputation (surgical removal) of toes 3, 4, and 5 on the left foot. Record reviews of the electronic health record on 05/31/2026 revealed no admission assessment, no MDS, no baseline care plan, and no comprehensive care plan were completed for Resident #45. During an interview on 05/31/2026 at 10:30 a.m., Resident #45 stated everyone was very nice at the facility, but he really just wanted to know what was going on with his care. He stated he was unsure what medications he was taking, was unsure who would do his wound care, when his MD appointments were, and when he was supposed to be evaluated by therapy. He stated no one had a meeting with him since he arrived on 05/28/2026 and he was unaware of what a baseline care plan was. During an interview on 06/02/2024 at 1:13 p.m., LVN A stated the charge nurse that admitted the new resident was responsible for starting the baseline care plan the day of admission and the social worker and administrative nurses were responsible for completing the baseline care plan. She did not know the baseline care plan needed to be completed within 48 hours. She stated the baseline care plan was important because it gave the residents a sense of ease knowing what the plan for their care was during their stay. During an interview on 06/02/2026 at 2:00 p.m., the DON said baseline care plans are used in place of a comprehensive care plan until one can be developed to direct resident care according to their goals and choices. The DON said the baseline care plan needed to be completed with each department and discussed with the resident and resident representative. The DON stated she was unaware of any negative effects that not having a baseline care plan could have on the residents. During an interview on 06/02/2024 at 2:15 p.m., the Administrator said the baseline care plans were an interdisciplinary form that was discussed with the residents on admit. The Administrator said it was the DON's responsibility to ensure the floor nurses completed the baseline care plan and provided a copy to the residents and family. Review of the undated facility policy titled Base Line Care Plan revealed .Completion and implementation of the baseline care plan within 48 hours of a resident's admission {was} intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and ensure the resident and representative, if applicable, are informed of the initial plan of delivery of care and services by receiving a written summary of the baseline care plan.

Based on interview and record review the facility failed to ensure a therapeutic diet was offered when there were nutritional problems and the therapeutic diet was recommended for 1 of 2 residents reviewed for nutrition.The facility failed to put interventions in place when Resident # 1 had poor intake related to swallowing food, inability to consume meals as result of physical decline. Resident #1 had a wound and did not receive a dietician consult as needed. Resident #1 did not have updated care plan interventions related to her change in condition . This failure could cause residents to lose weight and not have interventions in place that could lead to significant weight loss.Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of abnormal weight loss.Record review of Resident #1's annual MDS dated [DATE] indicated Resident was cognitively stable with a BIMS score of 13. Resident #1's functional abilities with eating was setup or clean up assistance. The MDS indicated the resident did not have any nutritional issues.Record review of Resident #1's care plan that was in the system on 9/9/25 indicated the last care plan interventions for weight loss was dated 2/6/25 with interventions to monitor and assist as needed. There were no current problems identified with weight loss, pressure wounds, or swallowing issues.During a record review and interview on 9/9/25 at 12:48 p.m. the ADON said there were no revisions regarding Resident #1's weight loss, swallowing or wounds since 2/6/25. There was a care plan intervention dated 8/14/25 that indicated Resident #1 was non-compliant with removing her boot from her leg. During an interview on 9/10/25 at 1:43 p.m. with the RNC and DON, they said some revisions to Resident #1's care plan and added some interventions. They said Resident #1's weight would not have triggered in their system because it did not go in until the 7th of the month. Record review of Resident #1's care plan on 9/10/25 with the RNC indicated additional interventions that were not present on 9/9/25 to include a problem with a initiation date of 7/5/25 of a fracture of Resident #1's left out ankle, with interventions of reporting abnormalities to the physician. A care plan problem dated 8/7/25 indicated impaired skin integrity. The resident had a wound to her left leg. Some of the interventions were a referral to wound care for weekly skin assessments, maintain adequate nutrition and hydration, and staff were to report any skin changes. A problem dated 9/5/25 indicated the staff reported the resident required medications to be crushed. This varied from nurse to nurse because she would swallow well for certain nurses. The interventions were she was referred to speech therapy, and the physician was to be notified of significant changes. Record review of Resident #1's computerized physician orders indicated an order dated 6/13/25 for a regular diet consistency, with thin liquids and no added salt. Record review of Resident #1's Nutritional Therapy assessment dated [DATE] indicated a regular diet with boost two times daily (order discontinued 4/6/25). She was to be monitored for significant weight changes, labs, skin issues, monitor oral intake of food and fluid.Record review of Resident #1's nursing note dated 4/6/25 indicated the house shake order was discontinued, the residents weighed monthly, and the dietician will reassess if needed according to policy. The Resident has a good appetite, eats in the dining room and often obtains multiple snacks between meals and has bedtime snacks form the snack cart. Record review of Resident #1's weight log indicated on 7/4/25 Resident #1 weighed 212.60 pounds. Record review of Resident #1's pre albumin (measures nutritional status, specifically protein and calorie intake) dated 7/10/25 indicated a prealbumin of 15 which was low with a normal range of (20-40.) Record review of Resident #1's physician orders indicated on 7/17/25 she was placed on weekly weights. Record review of Resident #1's weight log indicated on 7/20/25 she weighed 198.40 pounds.Record review of Resident #1 wound care note from the wound care doctor dated 8/7/25 indicated she had a no pressure wound on left leg identified when cast was removed. The wound was 4.1 x 3.6 x 0.3 cm. The note indicated a plan to discuss the patient's abnormal body mass index (32.95) with the current dietitian. If the patient does not currently have a dietitian following, recommend dietary consult. Record review of Resident #1's per albumin lab completed on 8/13/25 revealed the prealbumin was 9 -low with a normal range of (20-40.) Record review of Resident #1's wound care note dated 8/15/25 indicated the wound care doctor recommended a dietician consult for protein optimization.Record review of Resident #1's weight log indicated on 8/29/25 she weighed 193.40.Record review of Resident #1's nursing note dated 9/1/25 at 6:44 p.m. Resident having increased difficulty swallow suggested the resident took 1 pill at a time. The resident was having difficulty eating, the writer brought resident food today. She consumed only the soft portions, during dinner the resident tried mechanical soft with purred vegetables with no change with the amount consumed. The family was informed of the appetite decline. Resident #1 continue to want to go and smoke. Signed by LVN ARecord review of Resident #1's nursing note dated 9/2/25 at 3:29 p.m. indicated Resident #1 did not want to try and take medications at this time. The medications were crushed. Her appetite remained poor with only soft foods consumed. The resident continued to go outside, and smoke and she was medicated for pain prior to wound care. The Np was here and assessed the wound and regarding current health. Signed by LVN A Record review of Resident #1's physician wound care report dated 9/4/25 indicated Resident #1's wound had exacerbated due to the resident noncompliance with wound care. Record review of Resident #1's weight log indicated on 9/5/25 she weighed 183 pounds.On 8/15/25 the resident weighed 198.6 pounds and on 8/29/25 the resident weighed 193.4 with a loss of 5.2 pounds and 2.5 percent. On 9/25/25 Resident #1 weighed 183 pounds for a total of 10.4-pound weight loss at 7.76 percent. (Which according to staff and policy the last weight would not have been noted until 9/7/25.)Record review of Resident #1's nutrition follow-up note dated 9/9/25 indicated the resident was currently hospitalized . The resident was reported with a decreased oral intake prior to hospitalization. The resident was noted with a non-pressure wound to the right leg. Recommended diet as prescribed, add MVI, house shakes three times a day, and continue with vitamins C.During an interview on 9/9/25 at 1:50 p.m. the DON said the dietician had last seen evaluated Resident # #1 on 12/12/25. The DON said the dietician had not reviewed Resident #1's nutritional status. The DON said she was not aware of Resident #1's pre albumin being low, of her not eating, and that she had lost weight. She said today she had written a note because she had just triggered for weight loss. Record review Resident #1's hospital records dated 9/7/25 indicated she was admitted due to left foot pain and ankle pain. Resident #1's Albumin was 3.0 Low with a normal range between 3.5 and 5.7. Resident had a left ankle fracture in July after a fall and was treated with a boot cast, Following the removal of the cast she developed an ulcer over the left foot which has progressively worsened. During an interview on 9/9/25 at 2:03 p.m. the NP said she was told Resident #1 was refusing to eat. She said LVN A requested she go in and talk to Resident #1 on 9/2/25 because she had concerns Resident #1 was not eating and her wound appeared to be getting worse. She said she had talked to Resident #1 about eating and Resident #1 told her she was eating just fine. She said she had encouraged the resident to get her protein for wound healing. The NP said she was under the impression the Nurse said she changed Resident #1's diet order to a soft diet and had talked with therapy about ordering a swallow test. She said Resident #1 told her she did not have any problems. The NP said she did not know Resident #1 had lost that much weight. She also said the wound care physician had ordered the pre albumin and she was not aware it was low, no one had reported it to her. She said she had observed the wound on 9/2/25 and the wound was not healing. The NP said Resident #1 was non-compliant with recommendations of wearing the boot and elevating her foot to keep the swelling down. During an interview on 9/9/25 at 2:27 p.m. LVN A said Resident #1 would eat but wanted soft food, said she was having trouble swallowing. The LVN said Resident#1 ate about 25 percent. She said about a week ago she had bought her lunch that she said she wanted, however, Resident #1 would only eat soft stuff from the meal. LVN A said she had talked to speech therapist about Resident #1 not eating and they watched her a shot while. LVN A said she did not know Resident #1 was losing weight. She said the resident had really declined with her food intake the last two weeks. She said Resident #1 was non-compliant with recommendations of wearing the boot and elevating her foot to keep the swelling down. She said the resident wanted to stay up in her wheelchair and go out to smoke. LVN A said even when they tried to lay the resident down, she would hold her foot over the side of the bed and not elevate the foot to keep the swelling down. During your interview on 9/9/25 at 2:50 p.m. CNA F said one day last week Resident #1 was not eating very well especially during the last week or so.During an interview on 9/10/25 at 8:30 a.m. the dietary aide said she monitored the dining room daily. She said Resident #1 would take small bites and sometimes she said she could not swallow. The dietary aide said after Resident #1 had the cast on her foot, she did not eat well. She said the last couple of weeks Resident #1 did not eat very much at all. She said Resident #1 was on a regular diet. The dietary aide said it appeared Resident #1 was not able to eat solid foods so she would get her chopped meat to see if she would eat that and she still ate very little. She said the speech therapist was in the dining room one day about a week, and she asked her to look at Resident #1.During an interview on 9/9/25 at 5:40 p.m. with Resident #1 at the hospital. Resident #1 said she had not been feeling like eating. She said she just did not have an appetite. She said the facility staff knew she was not eating. She could not remember anything special they had done. Resident #1 said different staff encouraged her to eat but she had just not wanted the food. During an interview on 9/10/25 at 9:04 a.m. the Speech Therapist said on last week LVN A and an aide told her Resident #1 had swallowing issues. She said she did not know how long it had been going on but that morning when she watched her at breakfast, she was not eating at all. She had told her manager and on 9/2/25 they had submitted a request to see if Resident #1 qualified for therapy. During an interview on 9/10/25 at 9:17 a.m. the dietary manager said she had not gotten an order to change Resident #1's diet. She said Resident #1 was still on a regular diet. She said that the dietary aide would be the one that knew about Resident #1's eating. The dietary manger said the aide worked in the dining room with the residents. She said the dietary aide knew what the residents liked, what they did not like, what they would eat, and what they would not eat. She said the aide may have gone to the kitchen and request a mechanical soft meat for Resident #1, but no one had put in an order to change the consistency of her food.During an interview on 9/10/25 at 9:20 a.m. the dishwasher said she worked in the dining room from time to time. She said Resident #1 would nibble on her food and would not eat very well. She said that once she had broken her foot that her appetite appeared to decrease after that but more so the last couple of weeks. The dishwasher said it was hard to find something Resident #1 would eat. They would ask her if she wanted something else, but she would not eat very much. During an interview on 9/10/25 at 9:40 a.m. CNA E said that she worked from 6 a.m. to 2 p.m. She said Resident #1 said had not been eating for about two weeks. She said that she had kind of slowed down with eating over the last few months. CNA E said Resident #1 would rather smoke than eat most of the time. She said had reported to the LVN A. She said about two weeks ago Resident #1 was not eating. She said Resident #1 said she could not swallow. She said LVN A requested she go out and get some chicken (Resident #1's favorite meal), but Resident #1 only ate the soft stuff. She said the resident would not keep her boot on or her feet elevated. During an interview on 9/10/25 at 9:45 a.m. LVN G said that she worked PRN and the last time she worked with a Resident #1 was on Thursday, 9/4/25. She said the resident was confused and she had two falls on that day. She said that she was not eating and what she did eat it took her a longer time to eat her food. She said that day she crushed her medications because she said she could not swallow. Record review of the facility Treatment of Wound and Nutrition Related Wound Care policy dated July 2028 indicated the purpose was to insure residents with pressure ulcers received nutrition therapy that promoted optimal wound progress and prevention. The facility will request a referral for a qualified dietitian related to care plan development factors such as nutrition screening, nutrition assessment, care planning, energy intake, protein intake, hydration, vitamins and minerals. Record review of the facility Weight Monitoring policy dated May 19,2023 indicated the resident's weight will be monitored at a minimum monthly. If there is an actual weekly weight gain or loss of 2 percent the physician and registered dietitian would be notified. The monthly weights would be logged by the 7th calendar day of the month.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determines that drug records are accurate to meet the needs of each resident, for 1 of 2 residents (Resident #1) reviewed for medication administration.The facility failed to ensure Resident #1 had an order for Acetaminophen/Tylenol 650 mg every 4 hours as needed for pain/fever in the Electronic Medication Administration Record per the facility's standing orders. The facility failed to ensure LVN A documented the administration of Acetaminophen/Tylenol 650 mg every 4 hours as needed for Resident #1 on 07/17/2025. These failures could place residents at an increased risk for inaccurate drug administration and not receiving the care and services to meet their individual needs.Findings included:Record review of a face sheet dated 08/18/2025 indicated Resident #1 was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included sepsis (life threatening complication related to infection), diabetes mellitus (too much sugar in the blood), dependence of renal dialysis (life sustaining treatment for kidney failure) and hypertension (high blood pressure).Record review of the Discharge MDS assessment dated [DATE], indicated Resident #1 was able to make was able to make herself understood and understood others. The MDS assessment indicated Resident #1 had a BIMS summary score of 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #1 rarely had any pain that interfered with sleep, therapy or ADLs. Record review of Resident #1's Order Summary Report dated 08/18/2025 indicated she had an order for Acetaminophen/Tylenol 325 mg, two tablets by mouth every 4 hours as needed for pain started on 07/20/2025 and discontinued on 07/25/2025.Record review of Resident #1's care plan did not address pain.Record review of Resident #1's electronic medication administration record dated 07/17/2025 - 07/18/2025 did not indicate Acetaminophen/Tylenol had been administered.Record review of Incident Case Report dated 08/13/2025 documented by the DON, indicated Resident #1 alleged she had received her roommate's medication the evening of 07/17/2025. The report indicated, as LVN A walked into Resident #1's room, LVN A said to Resident #1's roommate that her Seroquel had been delivered as she walked through the room to administer Resident #1's medication. The report indicated that LVN A stated Resident #1's roommate mistook the information and thought LVN A had gave Resident #1 the (recently delivered from the pharmacy) Seroquel (medication used mental and mood conditions). The report indicated that Resident #1 and the roommate continued to insist LVN A had given the Seroquel to Resident #1. The report indicated LVN A told Resident #1 she would monitor her throughout the night for peace of mind and assured Resident #1 if she had given her the wrong medication .it would not cause her harm and would possibly make her sleepy. The report indicated, the DON had completed an assessment the next morning on 07/18/2025 and noted Resident #1 was somnolent but easily rousable and coherent. The report indicated, Resident #1 stated she felt sleepy, but not bad.During an interview on 08/18/2025 at 12:05 AM, CNA B stated on 07/18/2025 Resident #1 was hard to arouse, and she was unable to get her dressed. CNA B stated she was concerned because Resident #1 was always chipper and ready to get dressed in the mornings. CNA B stated after several attempts to wake up Resident #1 to no avail, she notified the DON.During an interview on 08/18/2025 at 12:31 PM, LVN A said she had given Acetaminophen/Tylenol to Resident #1 for pain around 10:30 PM on 07/17/2025. LVN A said she had a standing order for the prn medication and had not contacted the doctor. LVN A said someone had told her that Resident #1 was in pain and was waiting on the prn medication to be administered. LVN A said she could not recall why she did not document her assessment of Resident #1's pain on the required pain scale rating in the electronic medication administration record. LVN A said she guessed she was busy and forgot. LVN A said she it was important to document and complete pain assessments before and after giving pain medications to measure the need and effectiveness. LVN A said it was important to document the medication, dosage and time to prevent over medicating a resident which could result in toxicity. LVN A stated she was not aware that Resident #1 or the roommate thought she had given the roommate's Seroquel to Resident #1 on 7/17/2025. LVN A stated she first become aware on 07/18/2025 when the DON had contacted her by telephone. LVN A stated she did not tell Resident #1 she would monitor her throughout the night. During an interview on 0n 08/18/2025 at 02:02 PM, the Director of Rehabilitation stated Resident #1 was not acting her normal self. The Director of Rehabilitation stated Resident #1 was drowsy and unable to hold a conversation. The Director of Rehabilitation stated she notified the DON of the change and stated she did not take Resident #1 for therapy that AM. The Director of Rehabilitation stated the DON came to Resident #1's room and was able to arouse her and continued to get Resident #1 dressed. During an interview on 08/10/2025 at 01:10 PM, the DON said she was not aware LVN A had not completed the required pain assessment documentation on Resident #1 until today. The DON said when a prn medication was administered, the medication was entered on the electronic medication administration record. Then, the assessment record for pain would open for further documentation by the administering nurse to complete. The DON said it was important for coordination of care between staff and to monitor the proper effectiveness or lack of effectiveness that the Resident had experienced after taking the medication. The DON said if the medications were not documented after being administered, the resident was at risk of having too much or too little which could result in harm. The DON said she expected the staff to follow the protocol for medication administration. Record review of the facility's policy titled, Medication Administration General Guidelines, Pharmacy Policy & Procedure Manual Section 7.1 dated 01/24, indicated, .2. Facility staff administering medication shall comply with the following.1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure an opened box of powdered sugar was securely closed or stored in a secure container with a label and date. 2. The facility failed to ensure a plastic container with a lid, containing what appeared to be a red sauce in it, was labeled and dated. 3. The facility failed to ensure a plastic container with a lid, containing what appeared to be green beans, corn, and potatoes in it, was labeled and dated. 4. The facility failed to ensure a plastic bag containing an unknown meat with ice particles covering it was labeled and dated. 5. The facility failed to ensure a plastic bag containing what appeared to be chicken, with ice particles covering approximately half of it, was labeled, and dated. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During initial tour observations and interviews of the kitchen on [DATE] beginning at 9:20 AM and accompanied by the DM, there was a box of powdered sugar that had been opened in the dry goods pantry with the top of the box tabs closed,. tThe DM opened the box and the plastic bag on the inside of the box had a corner cut off and was not securely closed and it was not in a secured plastic zippered bag with label and date. The DM said the opened box of powdered sugar should have been placed in a plastic zipper bag and labeled and dated after it was opened. The DM went and got a plastic zipper bag and placed the opened box of powdered sugar in it. In the refrigerator, there was a clear plastic container with a lid containing what appeared to be a red sauce and there was no label or date on the container. There was also a clear plastic container with a lid containing what appeared to be green beans in the bottom, then yellow corn, and white cubes potatoes on top and there was no label or date on the container. DA G came over to the refrigerator and said the red sauce in the clear plastic container was ketchup and she had just put it in the refrigerator that morning and the other clear plastic container had mixed vegetables in it, but she did not know how long the mixed vegetables had been in the refrigerator. The DM came over and told DA G to toss both containers because they should have been labeled and dated. DA G told the DM she had just put the ketchup in the refrigerator that morning and would label and date it. The DM told DA G to toss the mixed vegetables because she did not know when they were put in the refrigerator. The DM said they should have been dated and labeled to show what was in the containers and when they were placed in the refrigerator. The DM was standing in front of the freezer, and she took a plastic bag of unknown meat, covered with ice particles, out and placed it on the counter and it was not labeled or dated. There was another plastic bag of frozen meat that appeared to be chicken with ice particles covering approximately half of it and it was not labeled or dated. The DM said everything should be labeled and dated. [NAME] F came over and said she had put the mixed vegetables in the clear plastic container and placed it in the refrigerator that morning prior to State Surveyor coming into the kitchen and the mixed vegetables were being served for lunch. [NAME] F said she should have labeled and dated the clear plastic container of vegetables when she placed it in the refrigerator. During an interview on [DATE] at 9:08 AM, [NAME] D said after opening a box of powder sugar, it should have been placed in a plastic bag and labeled, dated, and seal. [NAME] D said by placing the box in a plastic bag and sealing it, ensured nothing could get in it. [NAME] D said you should label and date anything before placing in the refrigerator or freezer. [NAME] D said it was important to label and date the food, so you could tell that it was not old or spoiled. [NAME] D said meat should be labeled and dated prior to placing it in the freezer. [NAME] D said the ice on the meat could mean it was freezer burnt. [NAME] D said she would not serve anything with ice covering it because it was not good. [NAME] D said the cook was responsible for ensuring food was labeled, dated, and stored properly. During an interview on [DATE] at 9:16 AM, DA E said she had worked at the facility for about ten years. DA E said when they open a package of powdered sugar, they should make sure the package was folded down and closed then placed in a plastic bag to keep it fresh and keep anything from getting in it. DA E said staff should label and date a container placed in the refrigerator prior to placing it in the refrigerator. DA E said containers in the refrigerator should be labeled and dated, so they can know what was in the container, and if dated, they know how long it had been in the refrigerator and whether it was still good. DA E said everything should be labeled and dated in the freezer. DA E said if food was placed in a plastic bag and was not labeled or dated in the freezer, then staff would not know how long it had been in the freezer and if it had ice on it, it could be freezer burnt and it meant it was not properly sealed and it had been in there too long. DA E said she would discard it after letting her supervisor know. DA E said they were all responsible for ensuring food was labeled, dated, and stored properly, but DM was the one ultimately responsible. During an interview on [DATE] at 9:25 AM, the DM said the powdered sugar was not stored properly. The DM said the powdered sugar should have been in a plastic bag and labeled and dated, because it was open, and it was not properly sealed. The DM said it was a constant battle to get her staff to label and date and she checked behind them regularly. The DM said the plastic containers in the refrigerator should have been labeled and dated prior to the staff placing them in the refrigerator so everyone would know when it was placed in it and if it was still good. The DM said the items in the freezer should have been labeled and dated and if there was ice on it, the staff know not to use it. The DM said ice on the meat meant it was freezer burnt and should not be served. The DM said the plastic unlabeled or dated bag of unknown meat was a hamburger patty. The DM said they have seen pests, roaches, in the kitchen occasionally, and when they see any pests, they notify the pest control man, and he was there on Friday [DATE]. The DM said she was responsible for ensuring staff stored and labeled/dated the food appropriately. The DM said they have gone through everything in the kitchen, the refrigerator, and the freezers, and they looked good now. During an interview on [DATE] at 11:10 AM, the ADM said she would expect food in the kitchen to be labeled, dated, and stored per the facility's policies. The ADM said the purpose of labeling, dating, and storing food per the facility's policies was to ensure the freshness of the food and to ensure that it was not expired. Record review of the facility's policy titled Nutrition Services dated revised February 6, 2024, indicated . food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination . Storeroom . air-tight containers or bags were used for all opened packages of food . all containers are accurately labeled with the item and date opened . Refrigerator . all foods are covered, labeled and dated . Freezer . foods are covered, labeled and dated . any item out of the original case must be properly secured and labeled .

47006 Based on observations, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 13 residents (Resident #12, #22, and #196) reviewed for infection control practices. 1. The facility failed to ensure signage was located outside Resident #196's room to indicate he required transmission-based droplet precautions. 2. The facility failed to ensure CNA C used transmission-based droplet precautions when entering Resident #196's room. 3. The facility failed to ensure CNA L changed her gloves and perform hand hygiene during Resident #12's indwelling foley catheter care. 4. The facility failed to ensure LVN A and CNA B followed the Enhanced Barrier Precautions (EBP) (interventions to prevent spread of infection in high-risk residents) policy of wearing a gown during Resident #22's wound care to right hip on 4/22/25. 5. The facility failed to ensure CNA B and CNA C followed the Enhanced Barrier Precautions (EBP) policy of wearing a gown during Resident #22's incontinent care on 4/22/25. These failures could place residents and staff at risk for cross contamination and the spread of infection. The findings included: 1. Record review of the face sheet, dated 04/22/25, reflected Resident #196 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of post COVID-19 condition and COPD (progressive lung disease characterized by chronic respiratory symptoms and airflow limitation). Record review of the MDS assessment list, accessed 04/22/25, reflected the admission MDS had not been completed yet. Record review of the comprehensive care plan, initiated 04/10/25, reflected Resident #196 had a contagious or infectious disease. The interventions included: isolation as ordered. Record review of the treatment order, accessed 04/22/25, reflected Resident #196 had an order, which started on 04/10/25 for isolation: droplet/respiratory x 21 days for diagnosis of post COVID-19 condition and positive test on 03/31/25. During an observation and interview on 04/21/25 beginning at 10:38 AM, Resident #196's door was open. There was no signage or PPE supply cart located outside room. There was a PPE supply cart across the hallway that had shoe covers, barrier cream, and biohazard bags in it. Resident #196 was sitting up in his chair with a mechanical lift pad underneath him. Resident #196 stated he had been on quarantine for a couple of weeks because he had COVID-19 in the hospital. Resident #196 stated today was supposed to have been his last day on quarantine. Resident #196 stated staff had not been wearing PPE when coming into his room. During an interview and observation on 04/21/25 beginning at 10:45 AM, CNA J stated she was responsible for the residents on 400 halls. CNA J stated she was unsure if Resident #196 required transmission-based droplet precautions. CNA J walked away to ask the nurse. CNA J returned to the surveyor and stated the charge nurse informed her Resident #196 was on transmission-based droplet isolation precautions. CNA J stated she did not ask the nurse why he was on transmission-based droplet precautions. CNA J stated she had not worn PPE in his room because she was not aware he required transmission-based droplet precautions. CNA C entered Resident #196's room during the interview with no PPE supplies on. During an observation and interview on 04/21/25 beginning at 10:47 AM, CNA C walked out of Resident #196's room and went into the clean linen closet. CNA C walked out of the clean linen closet with a blanket. CNA C stated she was getting Resident #196 a blanket because he asked for one. CNA C stated she believed Resident #196 was on transmission-based droplet precautions but was unsure why. CNA C stated she was not assigned to Resident #196's hallway. CNA C stated she should have worn PPE inside the room if he was on quarantine. CNA C stated it was important to ensure PPE was worn inside the room for someone on isolation precautions to prevent the spread of infection. During an interview on 04/21/25 beginning at 10:49 AM, LVN K stated Resident #196 was on transmission-based droplet precautions [isolation precautions related to an infectious disease, in which PPE should be worn] related to a COVID-19 diagnosis. LVN K stated there should have been signage located on the door to alert staff and visitors that PPE was required. LVN K stated the PPE worn should have included a mask. LVN K stated a mask should have been worn by anyone entering Resident #196's room. LVN K stated it was important to ensure signage was on the door to alert staff and visitor PPE was required, PPE was located outside the room, and staff wore the appropriate PPE to prevent the spread of infection. During an observation on 04/21/25 beginning at 10:51 AM, the ADON placed an isolation precaution sign outside Resident #196's room. The ADON moved the PPE supply cart in front of Resident #196's room and stocked it with gowns, masks, and gloves. During an interview on 04/23/25 beginning at 11:42 AM, the DON stated signage to alert staff or visitor that Resident #196 was on transmission-based droplet precautions should have been visible on his door. The DON stated all staff and visitors should have worn the appropriate PPE supplies when they entered Resident #196's room. The DON stated all the staff know the polices for infection control and were responsible for following them. The DON stated it was important to ensure signage was placed on the door and PPE was worn for residents with transmission-based precautions to reduce the spread of infection. The DON stated if there was no signage on the door, the facility staff should have reported it and placed a sign on the door. During an interview on 04/23/25 beginning at 12:09 PM, the Administrator stated she expected the facility staff to ensure appropriate signage and PPE supplies were available for residents who required transmission-based droplet precautions. The Administrator stated nursing staff were responsible for ensure the infection control policies and procedures were followed. The Administrator stated it was important to ensure signage was placed on the door and PPE was worn for residents with transmission-based precautions to reduce the spread of infection. 2. Record review of the face sheet, dated 04/23/25, reflected Resident #12 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of unspecified dementia with behaviors (memory loss) and chronic kidney disease (gradual loss of kidney function). Record review of the quarterly MDS assessment, dated 01/30/2025, reflected Resident #12 had clear speech and was sometimes understood by staff. The MDS reflected Resident #12 was rarely/never able to understand others. The MDS reflected Resident #12 had a BIMS score of 0, which indicated severe cognitive impairment. The MDS reflected Resident #12 had inattention and disorganized thinking that was continuously present and did not fluctuate. The MDS reflected Resident #12 exhibited refusal of care behaviors 1 to 3 days during the 7 day look-back period. The MDS reflected Resident #12 was totally dependent upon staff for assistance with toileting and had an indwelling catheter. Record review of the comprehensive care plan, dated 11/14/24, reflected Resident #12 had a urinary catheter. Record review of the treatment order, which started on 01/04/25, reflected Resident #12 had an order for a foley catheter. During an observation on 04/22/25 beginning at 4:13 PM, CNA L and CNA C entered Resident #12's room to perform foley catheter care. CNA L did not change her gloves or perform hand hygiene after wiping Resident #12's buttocks. CNA L placed the clean linens under Resident #12, pulled Resident #12's pants up, and re-placed her covers with the same gloves. During an interview on 04/22/25 beginning at 4:38 PM, CNA L stated her gloves should have been changed and hand hygiene performed when moving from dirty areas to clean areas. CNA L was unsure if she should have changed her gloves and performed hand hygiene after cleaning Resident #12's buttocks. CNA L stated she did not normally work at the facility, but she was picking up extra shifts. CNA L stated CNA C did not want to perform the foley catheter care because she was nervous. CNA L stated it was important to ensure gloves were changed and hand hygiene was performed to prevent infection. During an interview on 04/23/25 beginning at 9:57 AM, CNA C stated gloves should have been changed and hand hygiene performed when going from a dirty area to a clean area. CNA C stated she noticed CNA L did not change her gloves or perform hand hygiene when she performed catheter care but was unsure if she was supposed to tell her. CNA C stated not changing gloves or performing hand hygiene could have caused contamination of bacteria. During an interview on 04/23/25 beginning at 11:27 AM, LVN K stated she expected the CNAs to perform proper catheter care. LVN K stated gloves should have been changed and hand hygiene performed when moving from a dirty to clean area. LVN K stated it was important to ensure gloves were changed and hand hygiene was performed to prevent contamination. During an interview on 04/23/25 beginning at 11:42 AM, the DON stated she expected the CNAs to follow the policy and procedure for peri-care whether a resident has a catheter or not. The DON stated she expected gloves to be changed and hand hygiene performed when going from a dirty to a clean area. The DON stated the CNAs were responsible for monitoring to ensure catheter care was performed properly. The DON stated skills checkoffs were completed during orientation and annually. The DON stated it was important to ensure gloves were changed and hand hygiene was performed to prevent infection or being gross. During an interview on 04/23/25 beginning at 12:09 PM, the Administrator stated she expected facility staff to ensure proper catheter care was performed. The Administrator stated nursing management was responsible for monitoring to ensure proper catheter care was completed. The Administrator stated it was important to ensure proper catheter care was performed to prevent potential infections. 3. Record review of Resident #22's face sheet dated 4/22/25 revealed she was [AGE] years old and admitted to the facility on [DATE] and readmitted on [DATE]. Resident #22 had diagnoses including dementia (forgetfulness), cerebral infarction (stroke-lack of oxygen to the brain resulting in brain tissue death), weakness, and skin changes. Record review of Resident #22's annual MDS assessment dated [DATE] indicated she was sometimes understood and sometimes understood others. Resident #22 scored 0 on her BIMS, which indicated she had severe cognitive impairment. Resident #22 was dependent on staff for toileting and moderate assistance for most ADLs. The MDS indicated Resident #22 was always incontinent of bowel and bladder. Record review of Resident #22's Care Plan dated 4/22/25 indicated she had self-care deficit, skin breakdown, at risk for/actual, and infection control as evidenced by Enhanced Barrier Precautions with interventions for gown and glove use during high-contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, wound care, and any skin opening requiring a dressing. Record review of Resident #22's Orders dated 4/23/25 revealed an order for Enhanced Barrier Precautions (EBP) every AM shift (6 AM-2 PM) with a reason of wound, with a start date of 3/19/25. During an observation on 4/22/25 at 2:16 PM, LVN A performed wound care to Resident #22's right hip and was assisted by CNA B. Resident #22 had a blue name tag outside of her room door. CNA B sanitized hands and put on gloves, raised the bed, allowing the front of her clothing to touch Resident #22's bedding. CNA B then leaned over Resident #22 and pulled the blankets down to the end of the bed and assisted LVN A to pull the back of Resident #22's pants down allowing her clothing to touch Resident 22's bedding. CNA B then softly said, we forgot something, but did not say what they forgot. LVN A removed the old dressing from Resident #22's right hip, performed hand hygiene using hand sanitizer, changed gloves, then cleansed the wound with wound cleanser and gauze, then applied calcium alginate (used to heal wounds) on the wound, then covered the wound with the adhesive dressing. Then LVN A applied barrier cream (used to protective the skin from moisture) on Resident #22's bottom and then removed gloves and said Resident #22 had a bowel movement. CNA B then reached under resident to pull the draw pad out from under the resident, repositioned Resident #22 in bed by putting her arm under Resident 22's shoulders with her right arm and pulling her more upright in bed, allowing the front of her clothing to come in contact with Resident 22's clothing and bedding. CNA B said she would gather supplies and come back to provide incontinent care for Resident #22. CNA B and LVN A did not wear a gown as part of EBP while providing wound care to Resident #22. During an observation on 4/22/25 at 2:37 PM, CNA B performed incontinent care on Resident #22, assisted by CNA C. CNA C allowed Resident #22 to hold her hands during the care. CNA B pulled down Resident #22's bedding to the foot of bed and pulled down Resident #22's pants. CNA B then folded the soiled brief to contain the bowel movement away from the resident, then cleansed the rest of the bowel movement from Resident 22's bottom using cleansing wipes and pulled the soiled brief from under resident then cleansed her bottom again with cleansing wipes placing soiled items in a trash bag. CNA B then removed her gloves, sanitized her hands, and put on clean gloves. CNA B then reached over the top of the resident and reached under Resident #22 on the opposite side and pulled the clean brief from under Resident 22. CNA C assisted to turn Resident #22 leaning over resident and allowed the front of her clothing to come in contact with Resident #22's clothing and bedding. CNA B and CNA C did not wear a gown as part of EBP while performing Resident #22's incontinent care. During an interview on 4/22/25 at 2:52 PM, CNA B said she had worked at the facility for two days. CNA B said the blue name tags outside the residents' doors indicated they were on EBP. CNA B said if a resident was on EBP it meant you had to wear a gown and gloves to protect the resident from getting anything from the staff. CNA B said she knew they were in trouble when they provided wound care to Resident #22 and did not wear gowns. CNA B said not wearing gowns during wound care placed the resident at risk of catching any kind of germ or infection from the staff. CNA B said they should have been wearing gown and gloves during the wound care and incontinent care to protect Resident #22 from infections. CNA B said she had received training on EBP. During an interview on 4/22/25 at 2:56 PM, LVN A said she had worked at the facility for four months. LVN A said she did not remember what the blue name tags outside the resident's door was for. State Surveyor asked if the blue name tags had to do with EBP and LVN A said yes. LVN A said if a resident was on EBP, it meant to keep the resident turned and make sure their skin was good. State Surveyor asked what type of residents were on EBP, and LVN A said residents with wounds or urinary catheters were on EBP. LVN A said she did not know Resident #22 had a blue name tag and she then walked to Resident 22's door and verified there was a blue name tag and then said she should have worn a gown and gloves during the wound care to prevent the spread of infections. LVN A said not wearing gown and gloves while performing wound care placed the resident at risk for infections. LVN A said she had received training on EBP. During an interview on 4/22/25 at 3:02 PM, CNA C said she had worked at the facility for three days. CNA C said the blue name door tags meant staff had to wear a gown and gloves during personal care as precautions for residents with wounds or catheters. CNA C said staff should wear a gown and gloves to protect the resident from anything the staff may have on them. CNA C said when she went in to answer Resident #22's call light, when CNA B pushed the call light to get help, she (CNA C) didn't know she was going to be providing direct resident care and did not bring a gown. CNA C said they both should have been wearing gowns and gloves during the incontinent care to protect the resident from infections. CNA C said she had received training on EBP. During an interview on 4/23/25 at 10:52 AM, the DON said the staff knew residents were on EBP by the blue name tags by the door. The DON said residents with open wounds, urinary catheters, feeding tubes, or any implanted device in the body would be on EBP. The DON said Resident #22 was on EBP because she had wounds. The DON said gowns and gloves should be worn when providing care for residents on EBP. The DON said when staff were performing wound care and/or incontinent care they should be wearing a gown and gloves during care. The DON said the purpose of the EBP was to protect the resident from anything staff could bring into them. The DON said when staff did not follow the EBP policy of wearing a gown during care, it placed the resident at risk of infection. The DON said all staff were responsible for ensuring EBP was being followed and if she saw staff were not following the EBP policy, then she would definitely in-service the staff. The DON said they provided training on infection control and EBP policies upon hire and annually. During an interview on 4/23/25 at 11:10 AM, the ADM said the residents who were on EBP had a blue name tag on the door. The ADM said residents with wounds, urinary catheters, or any device inserted into the body would require the resident to be on EBP. The ADM said she would expect the staff to be following the EBP policy. The ADM said if staff did not follow the EBP policy it could place the resident at risk of contamination and/or infection. Record review of the Isolation Precautions policy, dated August 2018, reflected droplet precautions: intended to reduce the risk of respirator droplet transmission of infectious agents .enhanced barrier precautions: used when the resident does not require transmission-based precautions but has a higher risk of known colonization with MDROs .modified isolation precautions necessitates use of N95/KN95, face shield or goggles, gown, and gloves when entering the room .droplet precautions necessitates the use of a surgical/procedural mask and eye protections when entering the room .modified isolation precautions were used for the following situation: COVID-19 .place disease specific isolation sign on door .all personnel entering the room must wear isolation gown, gloves, N95/Kn95 mask, and eye protections such as goggles or face shield . Record review of the Urinary Catheter Infection Prevention policy, dated 08/2018, reflected hand hygiene is essential and the single most effect way to prevent the spread of infection .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 13 residents and 1 of 1 dining room reviewed for environment. (Resident #1, Resident #33, and Resident #96) 1. The facility failed to ensure Resident #1, Resident #33, and Resident #96 had furniture in good repair. 2. The facility failed to ensure the activity cabinet in the dining room was in good repair. These failures placed residents at risk of injury, an uncomfortable environment, and a decrease in quality of life and self-worth. Findings included: 1. Record review of the face sheet 04/22/25 indicated Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including dementia, pain, and convulsions (seizures). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 was usually understood and usually understood others. The MDS indicated a BIMS score of 08 indicating Resident #1 was moderately cognitively impaired. The MDS indicated Resident #1 required setup assistance from staff for ADL's. During an observation on 04/21/25 at 9:39 a.m., revealed Resident #1 was in bed. Resident #1's dresser was missing the front of the bottom drawer on the left side of the dresser. Resident #1's personal clothing items were exposed. The finish to the dresser was worn along the top edge and the front two lower corners and wood were exposed. During an observation and interview on 04/22/25 at 11:37 a.m., revealed Resident #1's dresser was missing the front of the bottom drawer on the left side of the dresser. Resident #1's personal clothing items were exposed. The finish to the dresser was worn along the top edge and the front two lower corners and wood were exposed. The resident said the dresser had been that way a long time. She said she had not reported it to anyone. 2. Record review of the face sheet 04/22/25 indicated Resident #33 was [AGE] years old and was admitted on [DATE] with diagnoses including dementia, impulse disorder (a mental health disorder that makes it difficult to resist urges), and hypoglycemia (low blood sugar). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #33 was usually understood and usually understood others. The MDS indicated a BIMS score of 10 indicating Resident #33 was moderately cognitively impaired. The MDS indicated Resident #33 required moderate to maximal assistance from staff for ADL's. During an observation on 04/21/25 at 9:49 a.m., revealed Resident #33 was in his chair in his room. Resident #33's dresser was missing the front of the second drawer down. Resident #33's personal items were exposed. During an observation an interview on 04/23/25 on 8:04 a.m., revealed Resident #33 was in his chair in his room. Resident #33's dresser was missing the front of the second drawer down. Resident #33's personal items were exposed. He said front of the drawer fell off a long time ago. He said he had not told anyone. He said, It is ugly like that. I thought they would bring me another dresser, but they have not. 3. Record review of the face sheet 04/22/25 indicated Resident #96 was [AGE] years old and was admitted on [DATE] with diagnoses including kidney failure, diabetes, and weakness. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #96 was usually understood and usually understood others. The MDS indicated a BIMS score of 12 indicating Resident #1 was moderately cognitively impaired. The MDS indicated Resident #96 required maximal assistance from staff for most ADL's. During an observation and interview on 04/21/25 at 11:51 a.m., revealed Resident #96 was in bed in her room. There was a wardrobe next to her bed. The front of the top drawer was only attached on one side and was hanging down. Resident #96's personal items were exposed. The handle to the door had a missing screw and was out of place. She said it had been broken the whole time she had been at the facility. During an observation on 04/22/25 at 11:39 a.m., revealed Resident #96 was in bed in her room. There was a wardrobe next to her bed. The front of the top drawer was only attached on one side and was hanging down. Resident #96's personal items were exposed. The handle to the door had a missing screw and was out of place. Record review of a Maintenance Work Order book that was kept at the nurse's station did not indicate work orders requesting repair of Resident #1 and Resident #33's dresser or Resident #96's wardrobe. During an interview on 04/23/25 at 9:05 a.m., CNA M said she had not noticed any broken furniture. She said any staff going in the room should notice broken furniture in a resident's room. She said any broken furniture should be entered into the Maintenance Work Order book at the nurse's stations. She said it is the Maintenance Supervisor's job to repair the furniture. She said broken furniture would not make her feel comfortable and like the staff did not care about her. During an interview on 04/23/25 at 9:20 a.m., LVN N said she had noticed the fronts of drawers missing off residents furniture. She said she never reported it to anyone. She said she had seen Resident #33's dresser missing a drawer front. She said furniture not being repaired could lead to a risk of splinters. During an interview on 04/23/25 at 9:47 a.m., the Maintenance Supervisor said he learned of furniture in need of repair either by work order or when he was in a room. He said he repaired what he could. He said sometimes he would go into a room and a drawer front would just be gone and someone had put it in the trash. He said he did not have extra furniture except for furniture from an empty room. He said he was not aware of the wardrobe in Resident #96's room. He said he had no clue where the front of the drawer was for Resident #33's dresser. He said he was not aware it was missing. He said he was not aware of the drawer missing a front in Resident #1's room. He said he had not been in her room in forever. He said none of these had been entered into the Maintenance Work Order book at the nurse's station. During an interview 04/23/25 at 10:23 a.m., the DON she said everyone was responsible for reporting broken furniture. She said there was a Maintenance Work Order book at the nurse's station and any request for repair should be entered into the book. She said she would then expect the Maintenance Supervisor to then address the issue. She said furniture in disrepair including loose handles could cause a balance issue and there could be sharp edges. She said also it could cause the residents personal items to be on display for everyone to see. During an interview on 04/23/25 at 10:40 a.m., the Administrator said all staff that entered a room that noticed anything that needed to be repaired should place a repair request in the Maintenance Work Order book. She said once it is entered into the Maintenance Work Order book, she then expected the maintenance supervisor to address the issue. She said furniture not being in good repair could be a care and concern for the resident. She said, I wouldn't like it. 4. During an observation on 04/21/25 at 11:28 AM, revealed the activity cabinet in the dining room had the right side of its doors removed, which were propped against the second cabinet. During an observation on 04/22/25 at 2:05 PM, revealed the activity cabinet in the dining room had the right side of its doors removed, which were propped against the second cabinet. During an interview on 04/23/25 at 10:44 AM, the Maintenance Supervisor stated the activity cabinet had not been reported to him, but he was aware the doors were broken. The Maintenance Supervisor stated the door was beyond repair and he had not been given approval to replace the cabinet. The Maintenance Supervisor stated he did not have extra furniture to replace the broken items. The Maintenance Supervisor stated it was important to ensure furniture was in good condition to prevent injuries and maintain a homelike environment. During an interview on 04/23/25 beginning at 12:09 PM, the Administrator stated she expected furniture to be in good repair. The Administrator stated the Maintenance Supervisor was responsible for ensure the furniture was fixed or replaced. The Administrator stated it was important to ensure furniture was in good repair to maintain a homelike environment. Record review of the Maintenance Service policy, undated, reflected Maintenance service shall be provided to all areas of the building, grounds, and equipment .the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .The following functions are performed by maintenance .maintain the building in good repair and free from hazards .providing routinely scheduled maintenance to all areas . 47006

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 13 residents (Resident #196) reviewed for accidents and supervision. The facility failed to ensure CNA H performed a safe mechanical lift transfer for Resident #196. This failure could place residents at risk of injury. Findings include: Record review of Resident #196's face sheet dated 4/22/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #196 had diagnoses which included dementia (forgetfulness), heart failure, hypertension (high blood pressure), and anxiety (feeling of worry). Record review of the MDS assessment list, accessed 04/22/25, reflected Resident #196's admission MDS had not been completed yet. Record review of Resident #169's Care Plan dated 4/22/25 indicated he was at risk for falls, and he had impaired physical mobility with intervention to provide appropriate level of assistance to promote safety of resident. Record review of Resident #196's weight dated 4/17/25 indicated he weighed 250.2 pounds. During an observation on 4/22/25 at 8:47 AM, CNA H performed a mechanical lift transfer for Resident #196 from his bed to his high back wheelchair and was assisted by CNA J. The lift pad was already positioned under Resident #196 upon entering the room. CNA H placed the mechanical lift over Resident #196 while CNA J was on opposite side of bed and they both hooked the straps to the mechanical lift. CNA H then lifted Resident #196 up without spreading the legs of the lift to the wide position. CNA J lowered the bed down so the mechanical lift and Resident #196 would clear bed. Then CNA H pulled the mechanical lift out from over the bed with Resident #196 suspended in the lift pad and turned the mechanical lift to the left and pushed the lift over to the high back wheelchair while CNA J guided Resident #196, without spreading the mechanical lift legs to the wide position. As CNA H pushed the mechanical lift toward the high back wheelchair approximately five feet away, CNA J said open the legs to CNA H. CNA H then spread the legs of the lift to go around the high back wheelchair, while CNA J locked the wheels on the wheelchair and pulled Resident #196 to the back of the wheelchair as CNA H lowered Resident #196 into the high back wheelchair. They then unhooked the lift pad and moved the mechanical lift away from Resident #196 and positioned him in the wheelchair for comfort and combed his hair. During an interview on 4/22/25 at 1:32 PM, CNA J said she had worked at the facility for three days this time but had worked at the facility previously. CNA J said the mechanical lift legs should be opened wide and locked prior to lifting the resident, so the lift would be balanced and would not tip over with the resident. CNA J said CNA H did not open the mechanical lift legs to the wide position prior to lifting Resident #196 off the bed and did not open the lift legs until CNA H had turned the lift toward the chair and opened the legs of the mechanical lift when she (CNA J) told CNA H to open the lift legs when she realized CNA H had not opened the lift legs to the wide position. CNA J said the mechanical lift could have tipped over and could have caused injury to the resident. During an interview on 4/22/25 at 1:37 PM, CNA H said she had worked at the facility since the end of January 2025. CNA H said the legs of the mechanical lift should be opened wide when going around the chair to be able to get around the chair when transferring a resident from the bed to the chair. CNA H said the purpose of the legs being open wide was to balance the lift and to be able to get around the chair to get the resident straight and even. CNA H again stated the legs of the mechanical lift should not be opened until going over and around the chair during the transfer. CNA H said she would have to look up the policy to know what the policy said about when to open the mechanical lift legs during mechanical lift transfers. During an interview on 04/23/25 at 10:52 AM, the DON said the legs of the mechanical lift should be opened wide when lifting and moving residents. The DON said the purpose of the mechanical lift legs being in the wide position was for stability. The DON said if the legs of the mechanical lift was not in the wide position during lifting or moving the resident, it placed resident at risk for injury if the mechanical lift was to fall over. The DON said they do competencies for safe mechanical lift transfers upon hire, and they did yearly skills check offs to ensure staff were performing safe mechanical lift transfers. During an interview on 4/23/25 at 11:10 AM, the ADM said she would expect staff to perform safe mechanical lifts per the facility's policy. The ADM said there was a risk of the resident falling or the mechanical lift falling over and injuring the resident if the legs of the lift were not in the wide position during lifting and moving the resident. During an interview on 4/23/25 at 12:33 PM, the DON said she was unable to locate the mechanical lift competency check off form for CNA H. Record review of the facility's policy titled Mechanical Lifts (Hoyer/Sit-to-Stand) dated revised February 12, 2020, indicated . residents would be assisted with their Activities of Daily Living, utilizing lifts according to manufacturer's guidelines . mechanical lift operators . c. inform resident of procedure . g. fold sling and place under patient in correct position . h. open feet of mechanical lift for wide stance . k. lift resident slowly and safely, just until off bed . l. move resident to other location and lower safely . Record review of Patient Lifts by the U.S. Food and Drug Administration (FDA), (Patient Lifts | FDA) was accessed on 4/24/25 indicated . the FDA has compiled a list of best practices that, when followed, can help mitigate the risks associated with patient lifts . users should . keep the base (legs) of the patient lift at maximum open position and situate the lift to provide stability . Record review of Best Practices for Using Patient Lifts by the U.S. Food and Drug Administration (FDA), Best Practices For Using Patient Lifts (fda.gov) was accessed on 4/24/25 indicated . patient lifts were designed to lift and transfer patients from one place to another . found improper use of patient lifts have led to patient falls . resulted in head traumas, fractures, deaths . can mitigate risks by doing the following . receive training and understand how to operate the lift . keep the base (legs) of the patient lift in the maximum open position .

Based on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident (Resident #38) reviewed for trauma-informed care. The facility did not ensure Resident #38 had a trauma screening completed upon admission to the facility that identified possible triggers when Resident #38 had a history of trauma. This failure could put residents at an increased risk for psychological distress due to re-traumatization. The findings included: Record review of the face sheet, dated 04/22/25, reflected Resident #38 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of unspecified dementia (memory loss). Record review of the admission referral packet, dated 11/08/24, reflected Resident #38 had a history of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the admission MDS assessment, dated 11/15/24, reflected Resident #38 had clear speech and was usually understood by others. The MDS reflected Resident #38 was usually able to understand others. The MDS reflected Resident #38 had a BIMS score of 11, which indicated moderately impaired cognition. The MDS reflected Resident #38 had wandering behaviors 1 to 3 days during the 7-day look-back period. The MDS assessment reflected Resident #38 had an active diagnosis of PTSD. Record review of Resident #38's comprehensive care plan, initiated 11/08/24, did not address a diagnosis of PTSD. The care plan did not identify potential triggers for re-traumatization. Record review of the admission assessment, signed 11/09/24, reflected Resident #38 had a mental health diagnosis of PTSD. Record review of the social services note, signed 11/13/24, reflected Resident #38 had no trauma screening or identification of potential triggers. Record review of the admission records list, accessed 04/22/25, reflected Resident #38 had no trauma screening completed upon admission. Record review of the social services record list, accessed 04/22/25, reflected Resident #38 had no trauma screening or trauma assessment completed since admission. During an observation and interview on 04/21/25 beginning at 10:12 AM, Resident #38 was sitting up in the bed. Resident #38 had a military plaque on his walls. Resident #38 stated he was in the military, specifically the air force. Resident #38 stated it messed me up. Resident #38 started fidgeting, moving around in the bed, and conversation became confused related to cognitive status. During an interview on 04/23/25 beginning at 10:23 AM, the Social Services Director stated trauma screenings were completed upon admission. The Social Services Director stated the nursing staff were responsible for completing the trauma screening. The Social Services Director stated she completed a more comprehensive assessment if the screening was flagged positive. The Social Service Director stated she was unsure if a trauma assessment was completed for Resident #38. The Social Services Director looked in the medical record and stated she was unable to find the trauma screening. The Social Service Director stated she was unsure if a diagnosis of PTSD would trigger a positive trauma screening. The Social Services Director stated a trauma assessment should have been completed upon admission to the facility. The Social Services Director stated Resident #38 should have been assessed further for potential triggers. The Social Services Director stated it was important to make sure residents were assessed for a history of trauma to ensure appropriate care and services were provided to the residents. During an interview on 04/23/25 beginning at 11:42 AM, the DON stated trauma screenings were completed on admission for all residents. The DON stated the admitting nurse was responsible for completing the trauma screening. The DON stated she was only made aware this week that the trauma assessment was not completed for Resident #38. The DON stated a diagnosis of PTSD would trigger a positive trauma screening and a more comprehensive assessment should have been completed by the Social Services Director. The DON stated it was important to ensure trauma screening were completed upon admission so residents who had a history of trauma could be treated appropriately with provided services. During an interview on 04/23/25 beginning at 12:09 PM, the Administrator stated she was just made aware this week that a trauma screening or assessment were not completed for Resident #38. The Administrator stated she was unsure what the policy and procedures were for PTSD or trauma assessments. The Administrator stated it was important to ensure trauma was identified so staff could prevent residents from reliving traumatic experiences and to provide the appropriate care and services. Record review of the Trauma Informed Care policy, dated 12/19/19, reflected Resident will be screened for Trauma upon admission, annually and as needed using the Trauma Screening and Recommendation in EMR . residents identified with a history of trauma, based on trauma screening and recommendations, will have trauma informed observations completed .traumatic events and triggers identified through the screening will be used to develop care plan .

Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 13 residents (Resident #12) reviewed for resident rights. The facility failed to ensure Resident #12's catheter drainage bag was in a privacy bag. This failure could place residents at an increased risk of embarrassment and a diminished quality of life. The findings included: Record review of the face sheet, dated 04/23/25, reflected Resident #12 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of unspecified dementia with behaviors (memory loss) and chronic kidney disease (gradual loss of kidney function). Record review of the quarterly MDS assessment, dated 01/30/2025, reflected Resident #12 had clear speech and was sometimes understood by staff. The MDS reflected Resident #12 was rarely/never able to understand others. The MDS reflected Resident #12 had a BIMS score of 0, which indicated severe cognitive impairment. The MDS reflected Resident #12 had inattention and disorganized thinking that was continuously present and did not fluctuate. The MDS reflected Resident #12 exhibited refusal of care behaviors 1 to 3 days during the 7 day look-back period. The MDS reflected Resident #12 was totally dependent upon staff for assistance with toileting and had an indwelling catheter. Record review of the comprehensive care plan, dated 11/14/24, reflected Resident #12 had a urinary catheter. The interventions included: use privacy bag. Record review of the treatment order, which started on 01/04/25, reflected Resident #12 had an order for a Foley catheter, which included privacy bag checked every shift. During an observation on 04/21/25 at 1:52 PM, Resident #12 was lying in her bed with her eyes closed. Resident #12's Foley catheter drainage bag was hanging on the bed rail visible from the doorway. No privacy bag was observed, and the drainage bag was filled halfway with yellow urine. Resident #12 was non-interviewable related to cognitive impairment. During an observation on 04/22/25 at 9:13 AM, Resident #12 was sitting up in her chair at the front lobby. Resident #12's Foley catheter drainage bag was hanging on the side of her chair. No privacy bag was observed, and the drainage bag had a small amount of yellow urine at the bottom of the bag. During an observation on 04/22/25 at 4:13 PM, Resident #12 was lying in the bed. Resident #12's Foley catheter drainage bag was hanging on the bed rail visible from the doorway. No privacy bag was observed, and the drainage bag had yellow urine. During an interview on 04/22/25 beginning at 4:38 PM, CNA L stated Resident #12 should have had a privacy bag on her catheter drainage bag. CNA L stated the CNAs should have made the nurses' aware if there was no privacy bag noted. CNA L stated it was important to ensure Resident #12 had a privacy bag on her Foley catheter drainage bag for dignity. During an interview on 04/23/25 beginning at 9:57 AM, CNA C stated Resident #12 should have had a privacy bag on her catheter drainage bag. CNA C stated she was nervous and did not notice if Resident #12's privacy bag was in place. CNA C stated if Resident #12 did not have a privacy bag available, she should have notified the nurse. CNA C stated it was important to ensure Resident #12 had a privacy bag on her Foley catheter drainage bag for dignity. During an interview on 04/23/25 beginning at 11:27 AM, LVN K stated Resident #12 should have had a privacy bag on her catheter drainage bag. LVN K stated she believed Resident #12 had a catheter drainage bag, but the CNAs probably lost it. LVN K stated she expected CNAs to report to the charge nurse if a privacy bag was missing so she could get another one. LVN K stated it was important to ensure a privacy bag was used for a catheter drainage bag for dignity. During an interview on 04/23/25 beginning at 11:42 AM, the DON stated she expected staff to notice if a privacy bag was missing, place a privacy bag if needed, or notify the charge nurse. The DON stated the CNAs should monitor to ensure privacy bags were in place, but any staff member could have noticed a missing privacy bag and notified the nursing staff. The DON stated it was important to ensure privacy bags were in place to maintain the dignity of the residents. During an interview on 04/23/25 beginning at 12:09 PM, the Administrator stated she expected staff to ensure a catheter drainage bag was inside a privacy bag. The Administrator stated the CNAs were responsible for ensuring privacy bags were used. The Administrator stated nursing management was responsible for monitoring to ensure privacy bags were utilized. The Administrator stated it was important to ensure privacy bags were used to promote the dignity of the residents. Record review of the Resident Rights policy, dated 08/14/2022, did not address dignity.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #12) reviewed for treatment and services related to indwelling catheters. 1. The facility failed to ensure CNA L changed her gloves and performed hand hygiene during Foley catheter care. 2. The facility failed to ensure Resident #12's indwelling Foley catheter had a catheter securement device to anchor the catheter to her leg. 3. The facility failed to ensure Resident #12's Foley catheter drainage bag was kept off the floor. These failures could place residents at risk for urinary tract infections, injuries, and a decreased quality of life. The findings included: Record review of the face sheet, dated 04/23/25, reflected Resident #12 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of unspecified dementia with behaviors (memory loss) and chronic kidney disease (gradual loss of kidney function). Record review of the quarterly MDS assessment, dated 01/30/2025, reflected Resident #12 had clear speech and was sometimes understood by staff. The MDS reflected Resident #12 was rarely/never able to understand others. The MDS reflected Resident #12 had a BIMS score of 0, which indicated severe cognitive impairment. The MDS reflected Resident #12 had inattention and disorganized thinking that was continuously present and did not fluctuate. The MDS reflected Resident #12 exhibited refusal of care behaviors 1 to 3 days during the 7 day look-back period. The MDS reflected Resident #12 was totally dependent upon staff for assistance with toileting and had an indwelling catheter. Record review of the comprehensive care plan, dated 11/14/24, reflected Resident #12 had a urinary catheter. The interventions included: use leg strap to avoid pulling to catheter. Record review of the treatment order, which started on 01/04/25, reflected Resident #12 had an order for a Foley catheter, which included placement of leg strap checked every shift. During an observation on 04/22/25 beginning at 4:13 PM, CNA L and CNA C entered Resident #12's room to perform Foley catheter care. Resident #12's pants were removed and there was no catheter securement device to anchor Resident #12's Foley catheter in place. CNA L did not change her gloves or perform hand hygiene after wiping Resident #12's buttocks. CNA L placed the clean linens under Resident #12, pulled Resident #12's pants up, and re-placed her covers with the same gloves. CNA C lowered Resident #12's bed to the floor after performing catheter care, in which her Foley catheter drainage bag was observed touching the floor. During an interview on 04/22/25 beginning at 4:38 PM, CNA L stated her gloves should have been changed and hand hygiene performed when moving from dirty areas to clean areas. CNA L was unsure if she should have changed her gloves and performed hand hygiene after cleaning Resident #12's buttocks. CNA L stated she did not normally work at the facility, but she was picking up extra shifts. CNA L stated CNA C did not want to perform the Foley catheter care because she was nervous. CNA L stated she noticed Resident #12's Foley catheter bag was on the ground after CNA C lowered her bed. CNA L stated a Foley catheter drainage bag should not have been touching the floor. CNA L stated Resident #12 did not have a catheter securement device on her leg to anchor the catheter. CNA L stated a catheter securement device should always be utilized to prevent injury from pulling. CNA L stated it was important to ensure gloves were changed, hand hygiene was performed, and the Foley catheter bag was kept off the ground to prevent infection. During an interview on 04/23/25 beginning at 9:57 AM, CNA C stated gloves should have been changed and hand hygiene performed when going from a dirty area to a clean area. CNA C stated she noticed CNA L did not change her gloves or perform hand hygiene when she performed catheter care but was unsure if she was supposed to tell her. CNA C stated not changing gloves or performing hand hygiene could have caused contamination of bacteria. CNA C stated Resident #12 normally had a clamp on her leg to prevent pulling of the catheter. CNA C stated she was unsure if it was policy to ensure catheter securement devices were in place. CNA C stated missing leg clamps should have been reported to the nurse. CNA C stated it was important to ensure the catheter securement devices was in place to prevent injury or pain from pulling. CNA C stated the Foley catheter drainage bag should not have been touching the ground. CNA C stated that was her fault and she was just thinking about Resident #12's safety. CNA C stated it was important to ensure the catheter draining bag was kept off the ground to prevent contamination of bacteria. During an interview on 04/23/25 beginning at 11:27 AM, LVN K stated she expected the CNAs to perform proper catheter care, ensure the catheter securement device was in place, and ensure the drainage bag was kept off the ground. LVN K stated gloves should have been changed and hand hygiene performed when moving from a dirty to clean area. LVN K stated it was important to ensure gloves were changed and hand hygiene was performed to prevent contamination. LVN K stated Resident #12 should have had a catheter securement device. LVN K stated the CNAs should have reported Resident #12 did not have one in place. LVN K stated she was unaware Resident #12's catheter securement device was missing. LVN K stated it was important to ensure Resident #12 had a catheter securement device in place to prevent pulling on the bladder. LVN K stated the catheter drainage bag should not have been touching the ground. LVN K stated it was important to ensure the catheter bag was kept off the ground to prevent leaking, degradation of the bag, or contamination. During an interview on 04/23/25 beginning at 11:42 AM, the DON stated she expected the CNAs to follow the policy and procedure for peri-care whether a resident has a catheter or not. The DON stated she expected gloves to be changed and hand hygiene performed when going from a dirty to a clean area. The DON stated the CNAs were responsible for monitoring to ensure catheter care was performed properly. The DON stated skills checkoffs were completed during orientation and annually. The DON stated it was important to ensure gloves were changed and hand hygiene was performed to prevent infection or being gross. The DON stated she expected the CNAs to ensure the nurse was made aware if a catheter securement device was missing. The DON stated it was important to ensure a catheter securement device was in place to prevent injuries. The DON stated she expected the CNAs to ensure the catheter drainage bags were kept off the ground. The DON stated everyone was responsible for ensuring catheter drainage bags were kept off the ground. The DON stated it was important to ensure the catheter drainage bag was kept of the ground to decrease the risk for infection. During an interview on 04/23/25 beginning at 12:09 PM, the Administrator stated she expected facility staff to ensure proper catheter care was performed, a catheter securement device was in place, and the catheter drainage bag was kept off the ground. The Administrator stated nursing management was responsible for monitoring to ensure those things were completed. The Administrator stated it was important to ensure proper catheter care was performed and the catheter drainage bag was kept off the floor to prevent potential infections. The Administrator stated a catheter securement device was important to prevent injuries from pulling. Record review of the Urinary Catheter Infection Prevention policy, dated 08/2018, reflected hand hygiene is essential and the single most effect way to prevent the spread of infection .the catheter is secured to the resident's leg to prevent unnecessary trauma . gravity drainage bags are kept off the floor .

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 2 of 13 residents reviewed for activities. (Residents #2 and Resident #33) The facility failed to provide Residents #2 and Resident #33 with consistent, scheduled activities. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: 1. Record review of the face sheet 04/22/25 indicated Resident #2 was [AGE] years old and was admitted on [DATE] with diagnoses including dementia, peripheral vascular disease (a condition where blood flow to the extremities, particularly the legs and arms, is restricted due to narrowing or blockage of blood vessels), and pain. Record Review of Physician's Orders for Resident #2 reviewed on 04/22/25 indicated an order for activities as tolerated with a start date of 08/18/23. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 was usually understood and usually understood others. The MDS indicated a BIMS score of 12 indicating Resident #2 was moderately cognitively impaired. The MDS indicated Resident #2 required supervision from staff for ADL's. Record review of a care plan last reviewed on 03/20/25 indicated Resident #2 had a need for socialization and had limited activity participation. There was an intervention to explore and obtain past interest and potential re-motivation. Record review of a Daily Participation form dated 02/20/25 indicated Resident #2 was active in all activities except for aromatherapy. Resident #2's electronic medical record did not indicate any Daily Participation forms since 02/20/25. During an observation and interview on 04/21/25 at 11:11 a.m., Resident #2 said she would like more activities. There was an activities calendar hanging on Resident #2's wall. She said, All we do is play bingo. She said when the previous Activity Director was there, they always had something to do. She said the previous Activity Director even had activities for them to do on the weekends. 2. Record review of the face sheet 04/22/25 indicated Resident #33 was [AGE] years old and was admitted on [DATE] with diagnoses including dementia, impulse disorder (a mental health disorder that makes it difficult to resist urges), and hypoglycemia (low blood sugar). Record Review of Physician's Orders for Resident #33 reviewed on 04/22/25 indicated an order for activities as tolerated with a start date of 08/20/24. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #33 was usually understood and usually understood others. The MDS indicated a BIMS score of 10 indicating Resident #33 was moderately cognitively impaired. The MDS indicated Resident #33 required moderate to maximal assistance from staff for ADL's. Record review of a care plan last revised on 02/13/25 indicated Resident #33 had a need for socialization with interventions to provide assistance to and from activities of interest, provide materials, equipment or supplies for preferred activity pursuits, and provide modifications and/or adaptations according to needs. Record review of a Daily Participation form dated 02/20/25 indicated Resident #33 was active in all activities except for aromatherapy and manicures. Resident #33's electronic medical record did not indicate any Daily Participation forms since 02/20/25. During an interview on 04/21/25 at 09:49 a.m., Resident #33 said the facility did not offer many activities. He said it was boring just sitting in his room. He said the other Activity Director sure kept us busy. He said the new Activity Director did not. Record review of an Activity Calendar for April 2025 indicated Balloon Volleyball was scheduled on 04/22/25 at 10:30 a.m. The calendar indicated Earth Day Scattergories was scheduled on 04/22/25 at 2:00 p.m. During an observation on 04/22/25 at 10:50 a.m., revealed there was no activity going on in the facility. During an interview on 04/22/25 at 11:01 a.m., the Activity Director said the morning activity did not happen. She said, Tthings got sidetracked. She said there would be an activity after lunch. During an observation 04/22/25 at 2:08 p.m., revealed there were 5 residents present in the dining room. There were no staff present. There was no activity in progress. During an observation on 04/22/25 at 2:15 p.m., revealed there were 5 residents present in the dining room. The residents were swatting balloons in the air with pool noodles. During an observation on 04/22/25 at 2:44 p.m., revealed there were residents in the dining room. There was not an activity in progress. During an interview on 04/23/25 at 8:04 a.m., Resident #33 said there was not an activity on the morning of 04/22/25. He said he did not know why. He said the Activity Director came and told him it was cancelled. He said, I just get bored sitting here. During an interview on 04/23/25 at 9:05 a.m., CNA M said she had not seen any activities while working at the facility. She said residents had not complained to her about not having enough activities. She said not having activities could affect them mentally and physically. It could cause someone to stay in the bed and could cause depression. During an interview on 04/23/25 at 9:20 a.m., LVN N said she knew residents had bingo and little activities. She said she had not heard any complaints about not enough activities. She said not having enough activities would not be fun and not having them could affect the resident's mentality. During an interview on 04/23/25 at 9:59 a.m., the Activity Director said she had made rounds to see what activities the residents would be interested in. She said no resident had complained to her about not having enough activities. She said in between her doing activities she also worked as the restorative aide and still drove the van occasionally. She said on the morning of 04/22/25 she was performing restorative aide duties and that was why the morning activity did not happen. She said she tried to arrange her restorative aide duties around the activities. She said her restorative duties could affect the activities on a daily basis. She said the restorative duties were causing her to not start activities at the scheduled time on the calendar. She said a lot of times it was hard to get the residents to attend activities. She said not having enough activities could cause the residents to be depressed. She said she would be bored out of her mind if she did not have activities to do. During an interview on 04/23/25 at 10:23 a.m., the DON said she had not received any complaints about residents not having enough activities. She said the Activity Director was very new to the position. She said the previous Activity Director held only one position. She said the new Activity Director was having to do the restorative program. She said the Activity Director should have been managing her time differently. She said she should be doing her restorative duties during other times. During an interview on 04/23/25 at 10:40 a.m., the Administrator said the Activity Director held two positions with the facility. She said she expected the Activity Director to provide activities to the resident. She said expected the Activity Director to be more spontaneous in the activities. She said Residents not having activities available could make them feel uninterested and bored. She said she would expect the Activity Director to follow the calendar or put another activity in the place of the one on the calendar. Record review of a Lifetime Wellness Policies and Procedures dated 01/01/23 indicated, .The wellness staff provides a variety of wellness and life enrichment activities that are designed to engage and enhance the quality of life for each resident we serve. Each facility and its residents have individualized programing needs. In response to these needs, services are customized for each facility .Group activities are scheduled daily and residents are given the opportunity to contribute to the planning, preparation, conducting and evaluation of the program .The program consists of facility-sponsored group (large and small) and individual activities and independent opportunities that are .designed to meet the interest of each resident .support the physical, mental and psychosocial well-being of each resident .

Based on interview and record review, the facility failed to ensure their activities program was directed by a qualified professional for 1 of 1 facility reviewed for Activity Director. The facility failed to employ a certified activities director. This failure could place the residents at risk of not receiving a program of activities that meets their assessed activity needs. Findings included: Record review of a personnel file for the Activity Director revealed did not indicate an Activity Director Certification and the Activity Director had 2 years of experience in a social or recreational program. The personnel file indicated a hire date of 05/08/19. Record review of a letter dated 04/02/25 and addressed to the Activity Director indicated confirmation of enrollment in a course to begin in August 2025 that taught the standardized National Council of Certified Activity Profession curriculum. During an interview on 04/23/25 at 9:59 a.m., the Activity Director said she became the Activity Director on 01/06/25. She said before that she was a CNA on the floor and worked in transportation. She said she had no experience being an activity director before she took the position. She said she had one training class but did not have her certification yet. She said in between her doing her activities she also worked as the restorative aide and still occasionally drove the van. During an interview on 04/23/25 at10:40 a.m., the Administrator said the Activity Director had been in the position since January 2025. She said the Activity Director had two positions. She said the Activity Director was enrolled for her Activities Directors class to begin in August 2025. She said the Activity Director had assisted the prior Activity Director with activities. She said not being certified, the Activity Director might not have all the knowledge needed for the position, but the Activity Director was being overseen by someone else that offers assistance and suggestions. She the Activity Director did have support. She said it would different if she did not have support. Record review of a Lifetime Wellness Policies and Procedures dated 01/01/23 indicated, .The wellness staff provides a variety of wellness and life enrichment activities that are designed to engage and enhance the quality of life for each resident we serve. Each facility and its residents have individualized programing needs. In response to these needs, services are customized for each facility .Group activities are scheduled daily and residents are given the opportunity to contribute to the planning, preparation, conducting and evaluation of the program .The program consists of facility-sponsored group (large and small) and individual activities and independent opportunities that are .designed to meet the interest of each resident .support the physical, mental and psychosocial well-being of each resident . The policy did not indicate the required qualifications for an Activity Director.

Based on observations, interviews, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 17 (Resident #1 and Resident #2) residents reviewed for call lights. The facility failed to ensure call lights were within reach while Resident #1 and Resident #2 were in bed. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: 1. Record review of Resident #1's face sheet dated 03/03/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia, amputation at knee level of right lower leg, and impulse disorder (a group of behavioral conditions that make it hard to control reactions or actions). Record review of Resident #1's annual MDS assessment dated [DATE], indicated he had a BIMs score of 10, which indicated she had moderate cognitive impairment. Resident #1 required maximal assistance or was totally dependent on staff for most ADLs. The MDS indicated Resident #1 was totally dependent for chair to bed transfers. The MDS indicated Resident #1 was always incontinent of bowel and bladder. Record review of Resident #1's Care Plan last reviewed on 01/16/25 reflected Resident #1 was a fall risk. There was an intervention to keep the call light and most frequently used personal items within reach. During an observation and interview on 03/02/25 at 8:57 a.m., Resident #1 said a lot of the time his call light was out of his reach, and he had to holler for help. Resident #1's call light was hanging on the privacy curtain at the foot of his bed. He said he could not reach it if he needed it. Resident #1 said this happened all of the time. 2. Record review of Resident #2's face sheet dated 03/03/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included overactive bladder, left femur (thigh bone) fracture, and major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life). Record review of Resident #2's latest MDS assessment dated [DATE], indicated he had a BIMs score of 8, which indicated he had moderate cognitive impairment. Resident #2 required moderate assistance or was totally dependent on staff for most ADLs. The MDS indicated Resident #18 was always incontinent of bladder and bowel. The MDS indicated Resident #2 had fallen in the last month. The MDS indicated Resident #2 had fallen 2 times with no injury and 2 times with injury since admission to the facility. Record review of Resident #2's Care Plan last updated 02/10/25 reflected Resident #2 was at risk for falls. There was an intervention to keep the call light and most frequently used personal items within reach. During an observation and interview on 03/04/25 at 11:25 a.m., Resident #2's call light was under the head of his bed on the floor. Resident #2 was watching television in bed. He said he did not know where his call light was. He said he would have to yell for help if he needed help. He said he only used his call light about once a week. During an observation on 03/04/25 at 2:13 p.m., Resident #2's call light was under the head of his bed on the floor. Resident #2 was watching television in bed. During an interview on 03/04/25 at 2:15 p.m., LVN C said it was the nurse's and CNA's responsibility to make sure residents had their call light. She said residents that could not reach their call lights might fall trying to get the call lights or not be able to call for help. She said Resident 1's call light should not have been attached to his curtain and should have been within his reach. She said Resident #1 did not use the call light. She said all residents should have their call lights within reach. She said she was not sure if Resident #2 used his call light or not. During an interview on 03/04/25 at 2:21 p.m., CNA E said everyone was responsible for making sure the residents could reach their call lights. She said anyone entering the room could see that call lights were not in reach. She said residents not having a call light could cause them to not get the help they needed in a timely manner. CNA E said it also increased the resident's risk for a fall if they got up to get something themselves. She said every resident should have their call light within reach. During an interview on 03/04/25 at 2:58 p.m., the DON said it was her expectation that residents have their call lights. She said anybody in the room was responsible for making sure the residents had their call lights. She said she would have expected for Resident #1 to have had his call light and it not be hanging on the curtain. She said she would have expected Resident #2 to have had his call light. She said she was not sure he would use it if he had it. She said a resident not being able to reach their call light could cause a fall or cause staff to miss a change in their condition. During an interview on 03/04/25 at 3:05 p.m., the Administrator said her expectations were for call lights to be within reach of the residents. She said if the resident was in need, staff would not know because they would not be able to call. Record review of a Call Lights Answer facility policy, last revised on 02/12/20 indicated, .The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately .when leaving the room, be sure the call light is placed within the resident's reach .

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 17 residents (Resident #4) reviewed for resident rights. The facility failed to ensure Resident #4 had a dignified existence by allowing her to be covered in feces on 2/27/25. These failures could place residents at risk of humiliation, diminished quality of life, loss of dignity and loss of self-worth. Findings included: Record review of Resident #4's face sheet dated 3/03/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #4 had diagnoses which included diverticulitis (occurs when an infected pouch becomes filled with pus) of large intestine with perforation (rupture) and abscess (pocket of pus), hypertension (high blood pressure), and depression (persistent sadness that can interfere with daily life). Record review of Resident #4's MDS assessment indicated it had not been completed prior to exiting the facility. Record review of Resident #4's care plan dated of 3/03/25 indicated she was taking an antidepressant (medication to treat depression); she had impaired physical mobility with an intervention to provide appropriate level of assistance to promote safety of resident; she had a self-care deficit with an intervention to provide assistance with self-care as needed; she was at risk for problems with elimination; and she had a colostomy/ileostomy (surgical procedure that created an opening in the abdominal wall through which waste products from the small intestine could exit the body). Record review of Resident #4's Progress Note dated 2/25/25 indicated Resident #4 had an ileostomy due to a perforated (ruptured) diverticulitis and a large midline surgical incision with staples and dehisced area (open/separation of wound edges) to the end of the incision near the ileostomy and it was being packed with saline soaked gauze. NP F documented the ileostomy bag had dark liquid stool in it. Record review of Nurse Note dated 2/28/25 at 6:45 AM indicated LVN A had come on duty on 2/27/25 at about 1910 (7:10 PM) and was informed by LVN C, Resident #4's family was there and was upset that Resident #4 had bowel all over her and her wound from her leaking colostomy bag. LVN A documented Resident #4's clothing and brief were soiled with bowel from her leaking colostomy bag, as well as the dressing covering the wound. LVN A documented Resident #4's family member stated Resident #4 had been sitting in poop for four hours. During an observation and interview on 3/03/25 at 11:50 AM, Resident #4 was lying in bed visiting with two family members in her room. Resident #4 said since her FM #1 fussed at the facility on 2/27/25, things had been much better and they now checked on her hourly and emptied her colostomy bag, but the first three days at the facility were awful. Resident #4 said the staff did not empty her colostomy bag and it burst the first night she was at the facility and covered her in poop and it frequently leaked. Resident #4 said she laid in her own poop and had poop in her wound that was by her colostomy frequently for the first three days, but the worst time was on 2/27/25. Resident #4 said they had issues on 2/27/25 four times during the day with her colostomy bag leaking and the nurse had changed it a couple times earlier in the day, but it would be back to leaking shortly after it was changed. Resident #4 said she laid in her own poop for about four hours until FM #3 came to see her. FM #2, who was visiting with Resident #4, said she had called Resident #4 at 3:00 PM and Resident #4 said her colostomy bag was leaking and no one had come to answer her call light and she was lying in her own poop. FM #2 said she called the facility about 3:30 PM and no one answered the phone. Resident #4 said she knew she had been lying in her own poop for about four hours based off the time of the phone calls with FM #2. Resident #4 said by the time FM #3 arrived in her room a little after 7:00 PM, she was covered in her own poop. Resident #4 said when FM #3 entered the room, he said, what is that smell and Resident #4 said she was crying and threw back the covers and she told FM #3 it was her because no one had fixed her leaking colostomy and she was covered in her own poop. Resident #4 said she laid in her own poop until her FM #3 arrived at the facility, and he went to try to get someone to clean her up and was told by staff that it was not their jobs and would have to get the nurse. Resident #4 said it was about 8:00 PM before they finally started cleaning her up. Resident #4 said it was embarrassing to be covered in her own poop and the smell was awful. Resident #4 said they were not answering her call light timely which led to her colostomy bag getting too full and it pulled away from the skin from the weight and then it would start leaking. Resident #4 said at times the CNA would come by and would tell her it was not their job to empty it, and she would have to get the nurse, but no one came. Resident #4 said a CNA did offer to change her gown on 2/27/25 but what good would that have done when everything was covered in poop and her leaking colostomy was continuously producing more liquid poop. Resident #4 said she had been told the nurse would be coming to change the colostomy bag, but she did not come. During an interview on 3/4/25 at 10:37 AM, FM #3 said he arrived at the facility at 7:00 PM per his life 360 application on his phone. FM #3 said he walked into Resident #4's room and opened her door and said, what is that smell and Resident #4 pulled her covers back and she had poop from her chest to her knees and she was crying. FM #3 said he went down the hall and saw someone on her phone and asked her, who was going to clean Resident #4 up. He said she said it was not her job and she would go get someone. FM #3 said Resident #4 said she had been sitting in poop for almost for four hours. FM #3 said he then saw a nurse he knew coming in the front door and asked her to come down to Resident #4's room. FM #3 said when the nurse walked into the room she said, O my and said she would get Resident #4 taken care of. FM #3 said the nurse cleaned on Resident #4 for almost two hours. FM #3 said there was no excuse for the state Resident #4 was in. FM #3 said someone should have tended to her colostomy bag long before it got to the point it did with covering Resident #4 in her own poop. During an interview on 3/4/25 at 10:58 AM, LVN A said she was late coming in for her shift (6 PM-6 AM) on 2/27/25 and arrived around 7:10 PM. LVN A said the day shift nurse (LVN C) was in a tizzy and said she (LVN A) would have to go deal with Resident #4's family because they were cussing at LVN C. LVN A said she went into Resident #4's room and she had poop everywhere, in the wound, in her brief, in the bed and linens, and covering her gown from her chest to below her knees. LVN A said she went and gathered all the supplies she would need to clean Resident #4 up, change the colostomy bag, and clean and redress her wound, and then went back to Resident #4's room. LVN A said it took her about two hours to clean Resident #4 up, change the colostomy, and clean and redress her wound. LVN A said, let's just say if that was my mother, I would have flipped my you know what, if I had found her like that. LVN A said some of the feces was dried with brown ring edges on the bedding and some was still liquid. LVN A said the dried feces with brown ring edges indicated it had been there for a while, but she was not sure how long it would have taken it to dry. LVN A said she was sure it embarrassed Resident #4 and made her feel awful and it was probably irritating to her skin. LVN A said the entire ordeal was embarrassing for Resident #4. During an interview on 3/4/24 at 11:20 AM, CNA B said she had gone into Resident #4's room a little while before her family arrived and she asked Resident #4 about changing her gown due to her colostomy bag was leaking. CNA B said she placed a towel under Resident #4 and over her gown because Resident #4 said she wanted to wait until after the nurse changed the colostomy bag. CNA B said the colostomy bag was leaking and it would be the nurse that would have to change it. CNA B said she had come in to work the 2 PM to 10 PM shift. CNA B said she had not emptied the colostomy bag during her shift. CNA B said she did not know she could empty the colostomy bag. CNA B said they had been having issues with the colostomy bag leaking that day. CNA B said the nurse would have been responsible for ensuring the colostomy bag was not leaking and for emptying it because she was unaware, she could empty the bag. CNA B said Resident #4 probably felt disgusted and dirty lying in her own feces. During an interview on 3/4/25 at 12:19 PM, LVN C said she had worked at the facility for about a month on the 6 AM-6 PM shift. LVN C said the CNAs were going into Resident #4's room regularly on 2/27/25. LVN C said she emptied the colostomy bag three times herself and changed the bag twice during her shift and was not sure why the family was saying that she had been lying in feces for four hours. LVN C said no one had told her that Resident #4's bag was leaking, and she was confused when FM #1 was yelling at her that it had leaked, she did not know there was an issue with it leaking. LVN C said FM #3 had asked her when they were going to clean her up and then FM #1 showed up and started yelling at her. LVN C said she was going to give another resident pain medication and then come back and take care of Resident #4. LVN C said she was not told that the resident was covered in feces on 2/27/25. LVN C said she did not witness what the Resident #4 looked like prior to her family arriving. LVN C said it would be embarrassing to Resident #4 and it could cause an infection to be covered in her own feces. During an interview on 3/4/25 at 3:30 PM, the DON said she had gotten a phone call about a family member being at the facility and was yelling and screaming and a couple of the CNAs felt threatened by the family member's body language toward them on 2/27/25. The family member was making allegations that Resident #4 had not been cared for and left covered in feces. The DON said she then called the ADM, and the ADM came to the facility. The DON said there was an issue with getting the colostomy bag to seal, due to the placement of the ileostomy and her open wound, and it would leak. The DON said she would have been responsible to ensure that staff were knowledgeable of caring for the colostomy and care was being provided timely. The DON said she was not sure how long it would take for stool to dry, maybe a couple of hours. The DON said if there were dried brown circles it would be indicative that the stool had been there for a while. The DON said Resident #4 could have skin issues and there was the dignity issue of having feces on her. The DON said the aide did offer to clean her up, but the resident declined because she wanted to wait until the nurse came to change her colostomy. During an interview on 3/4/25 at 4:00 PM, the ADM said Resident #4 had only been in the facility for three days and she had not gotten any complaints from Resident #4 until her FM #1 was at the facility cussing staff and saying Resident #4 had not been cared for. The ADM said Resident #4 had not told her about having frequent leaking from her colostomy bag. The ADM said when the colostomy bag would get to a certain level Resident #4 wanted it emptied. The ADM said Resident #4 told her that staff would come in and say that they were coming back and did not come back quickly. The ADM said FM #1 told her Resident #4 had feces all over her on 2/27/25. The ADM said she came to the facility on [DATE] during the incident with Resident #4's family, but the nurse had already been cleaning up the resident and the ADM said she did not see any of the issue. The ADM said being covered in feces could make the resident feel like she was not being cared for. The ADM said the resident had told her the aide had offered to change her and the resident declined because she was waiting for the nurse to return and change the colostomy bag. Record review of the facility's Training In-service Form dated 2/28/24, titled Customer Service, Rounding, Call lights, Abuse/Neglect, and Providing Care in a timely manner, indicated . CNA Inservice . routine rounds were important . not only for incontinent care . residents depend on us to notice when something was right . the earlier we notice a change, the better the outcome . call lights should be answered timely . if the resident's need is out of your scope of practice, ensure the resident that you will locate the appropriate staff, then do so . emptying, and cleaning ostomy bags and the skin around them IS within your scope of practice and you are expected to perform this duty . if the ostomy bag itself has become dislodged, clean the area, place a towel for comfort, and inform the resident's nurse immediately . provide care to residents in a timely manner . if you cannot attend to the resident's request immediately, give them a time frame in which you will return and then make sure you adhere to that time frame . this alleviates some of the anxiety they feel when waiting for care . Review of the facility's policy titled Resident Rights dated revised August 14, 2022, indicated . the staff would abide by and protect resident rights in accordance with state and federal guidelines .

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 14 residents (Resident #1) reviewed for abuse and neglect in that: The facility failed to suspend an alleged perpetrator immediately following CNA A roughly handling Resident #1 during ADL care. The facility allowed CNA A to work 7 more shifts before suspension while investigation the abuse allegations, and the facility failed to report the abuse within 24 hours to the state agency. The ADON and CNA B failed to report the abuse to the abuse coordinator immediately. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 04/09/2024 and ended on 04/17/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse timely. Findings included: Record review of the facility's policy and procedure, titled Reporting Abuse and Neglect Policy, revision date March 2018, .'With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee will immediately be suspended pending an investigation' .'The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 .a. If the allegations involve abuse or result in serious bodily injury, the report is made within 2 hours of the allegation. If the allegations do not result in serious bodily injury, the report is made within 24 hours of the allegation. Record review of an undated face sheet indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), major depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anemia (low iron in the blood), and congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should). He discharged [DATE]. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 11, which indicated mild cognitive deficit. Resident #1 required moderate assistance for ADLs such as bed mobility, transfer, and toileting. Record review of a care plan dated 04/03/2024 titled ADL assistance indicated Resident #1 had an ADL self-deficit. The intervention for Resident #1 revealed the staff was to assist resident as needed with ADLs. During an interview on 08/29/2024 at 2:00 p.m., Resident #1's family member stated there was a camera in Resident #1's room while he was a resident at the facility. She stated that on more than one occasion the staff treated Resident #1 poorly by the way they handled him. Resident #1's family member provided video evidence of the staff mistreating him on 04/09/2024. She stated Resident #1 was upset about the mistreatment and more upset they allowed CNA A to continue to work with him after she had been so rough with him during his care. She reported to the ADON on 04/09/2024 that the video showed her Resident #1 being handled in an abusive manner. Record review of video evidence on 09/03/2024 at 8:00 a.m. revealed the following: Video footage dated 04/09/2024 5:29 p.m., began with Resident #1 sitting on the side of the bed in his room with his feet dangling above the floor holding on to the edge of the mattress. CNA A was standing behind the left side of the resident's bed about 3 feet. CNA B was standing in the front of the resident's bed about 6 feet. Resident #1: Where are we going? This isn't working. I'm going to fall. CNA A: Then put your feet in the bed. Resident #1: I'm gonna fall, please help. CNA A: {Resident #1's first name}, put your feet in the bed. Resident #1: I can't put my feet in the bed. CNA A: Put your feet in the bed {Resident #1's first name}! Resident #1: I'm falling! I'm about to fall! CNA A moved around the bed in front of Resident #1. She grabbed his ankles and quickly lifted them and shoved them onto the mattress. CNA B was in the same position 6 feet from the bed and had not moved to assist. Resident #1: Ow, God, do you have to be so rough? CNA A: You are a big man, and I am not hurting myself messing with you. Resident #1: You don't have to be so rough with me. CNA A: I told you; you are a big man and I have a bad shoulder. I am not hurting myself trying to help you. Resident #1: You do not have to be rough with me. Just please don't be rough with me. CNA A: You are right I don't have to do it because I don't even have to be here. You are the one that needs help. You can't be telling people how to help you. CNA A to CNA B: Come over here and roll him because he is not going to do anything for himself. CNA B walks towards Resident #1 to assist with perineal care. End of video clip During an interview on 9/04/2024 at 10:00 AM, the ADON stated she was made aware of the actions of CNA A to Resident #1 by Resident #1's family member on 4/09/2024 around 1:00 p.m. She stated she viewed the video, and it was apparent to her CNA A was being mean to Resident #1, but she was not sure it would have been considered abuse by the abuse coordinator. She stated she brought it to the attention of the DON and Administrator the next week because they were both on vacation at the time, and after suspension for her behavior and attitude CNA A was terminated. The ADON stated it was against Resident #1's rights to be mistreated and disrespected by being roughly handled by the staff. During an interview on 09/04/2024 at 3:00 p.m., the DON stated it was brought to her attention by the ADON on 04/17/2024 that CNA A was being abusive to Resident #1, and it had been recorded by Resident #1's family member. The DON stated as soon as she was told about the incident, she called CNA A to let her know she was suspended until it was determined what happened and she was required to complete education on abuse before being able to come back to work. The DON stated after reviewing the video it was determined CNA A's services were no longer needed at the facility because abusive behavior was confirmed. She stated mistreatment of the residents was not allowed. The DON stated CNA A and CNA B was terminated on 04/17/2024. The DON stated the ADON was written up and received immediate one on one abuse and neglect training that included reporting protocol and timelines. During an interview on 09/04/2024 at 3:30 p.m., the ADM stated CNA A was terminated from the facility specifically related to her treatment of Resident #1. She stated the ADON was counseled on the abuse policy of the facility and was educated on reporting abuse to the abuse coordinator immediately and that the abuse coordinator had only 2 hours to report to HHS once abuse was suspected or confirmed. The ADM stated by not reporting the abuse immediately CNA A was allowed to work 7 more shifts with the same resident and other residents that she potentially could have abused. The ADM stated safe surveys were completed and the entire staff was inserviced on types of abuse, who the abuse coordinator was, and reporting time frames. The facility had corrected the noncompliance on 04/17/2024 by the following: - Termination of CNA A who was responsible for the abuse - Termination of CNA B who was responsible for not reporting the abuse to the Abuse Coordinator - Written counseling of the ADON with education on the reporting process - Safe surveys of all the residents in the facility - 100% staff in-service on abuse and neglect and reporting - Backup plan established, and staff educated for the absence of the abuse coordinator (ADM) and the DON. Staff to notify corporate [NAME] President of Operations. Record review of a Quality Assurance (QA) Meeting Sign-in Sheet dated 04/18/2024 indicated the facility had an QA meeting addressing abuse reporting. The QA Meeting Sign-in Sheet indicated the ADON, DON, ADM, NP, dietary manger, housekeeping supervisor, floor nurses, and CNAs attended the meeting. Record review of the sampled residents (Resident #6, Resident #7, and Resident 38) revealed abuse allegations were reported timely to the abuse coordinator and HHS. All staff interviewed (CNA E, LVN G, ADON, CNA H, and LVN K) on 09/03/2024 verbalized any allegation of abuse should be reported to the administrator immediately. They verbalized understanding of the types of abuse and the facility's obligation to report abuse to HHS within 2 hours. The noncompliance was identified as PNC. The noncompliance began on 04/09/2024 and ended on 04/17/2024. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 2 of 8 residents reviewed for accidents. (Resident #3 and Resident #5) 1.The facility failed to ensure CNA D performed safe repositioning with two staff members during incontinent care for Resident #3 on 3/26/24, which resulted in Resident #3 falling off the bed and required stitches to the inside of her lip. 2. The facility failed to transfer Resident #5 with the required 2 people for a safe mechanical lift transfer from his bed to his chair. These failures could place residents at risk of injury from accident and hazards. Findings included: 1.Record review of Resident #3's face sheet dated 8/29/24 indicated she was [AGE] years old and admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (disruption of blood flow to the brain, resulting in parts of the brain dying), abnormalities of gait and mobility, lack of coordination, and diabetes (high blood sugar). Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated she was rarely/never understood and sometimes understood others. The MDS indicated a Resident #3 had a BIMS score of 00, which indicated she had severe cognitive impairment. The MDS indicated Resident #3 had inattention continuously (easily distracted) and disorganized thinking continuously (rambling or irrelevant conversation). The MDS indicated Resident #3 required extensive assistance of two persons for bed mobility, toileting, and personal hygiene. The MDS indicated Resident #3 was totally dependent on 2 persons assistance during bathing. The MDS indicated Resident #3 was always incontinent of bowel and bladder. The MDS indicated she had diagnoses of cerebral infarction, aphasia (difficulty speaking), and hemiplegia or hemiparesis (unable to move or weakness on one side of the body). Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated she was rarely/never understood and rarely/never understood others. The MDS indicated a Resident #3 was rarely/never understood and unable to complete BIMS, which indicated she had severe cognitive impairment. The MDS indicated Resident #3 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #3 had inattention continuously (easily distracted) and disorganized thinking continuously (rambling or irrelevant conversation). The MDS indicated Resident #3 had limited range of motion to both upper and lower extremities on one side of the body. The MDS indicated Resident #3 was dependent on staff for toileting hygiene and rolling left and right in bed. The MDS indicated she was always incontinent of bowel and bladder. Record review of Resident #3's Fall Risk assessment dated [DATE] indicated she scored 15, a score of 7-18 indicated she was high risks for falls. Record review of Resident #3's care plan printed on 8/29/24 indicated Resident #3 had impaired physical mobility with an onset of 3/03/23 and an intervention to provide appropriate level of assistance to promote safety of resident. The care plan indicated Resident #3 had impaired physical mobility with a reviewed date of 3/04/23 as evidenced by right upper and lower extremity weakness; interventions included provide appropriate level of assistance to promote safety of resident, required assistance of one staff, required assistance of two staff, required extensive assistance, and required limited assistance. The care plan indicated Resident #3 was a high fall risk with an onset of 3/04/23 as evidenced by right upper and lower extremity weakness. Record review of Resident #3's Vital Sign report printed on 9/04/24 indicated she weighed 237 pounds on 3/06/24. Record review of Resident #3's Nurses Note documented on 3/26/24 at 2:46 AM by LVN C indicated the CNA notified her of Resident #3 had rolled out of the bed and was on the floor. LVN C arrived and observed Resident #3 lying face down and had small amount of bright red blood to head area. Resident #3 was assessed and found to have appeared to have bitten the inside of her lip with blood to mouth and her left eye slightly swollen with discoloration noted, and Resident #3 complained of right shoulder pain. Resident #3 was sent to the emergency room . LVN C documented on 3/26/24 at 3:49 AM, Resident #3 received three stitches to right upper inner lip and her head scans were clear. Record review of the facility's PIR dated 3/26/24, indicated Resident #3 was observed lying face down at bedside by LVN C after rolling off the bed attempting to reach something on her bedside table during ADL care. CNA D stated she turned Resident #3 to her right side and Resident #3 reached for something and rolled off the bed. Resident #3 had a small laceration to the inside of her upper lip and small abrasion to head and bruising to left and right eyes. Resident #3 was transferred to the hospital and received three stitches to inside of her lip. Attempted to call Resident #3's responsible party on 8/29/24 at 1:47 PM and on 9/3/24 at 1:08 PM, but there was no answer, a voice mail was left requesting a return call. Resident #3's responsible party did not return call prior to exiting the facility. During an observation and interview on 9/4/24 at 8:36 AM, Resident #3 was sitting up in bed with her breakfast tray in front of her with most of the food gone. Resident #3 said she was doing good and had a good breakfast. Resident #3 said she did not remember rolling out of bed and busting her lip. Resident #3 said no one had been mean to her and they took good care of her. Attempted to call CNA D on 9/3/24 at 3:19 PM and 9/04/24 at 11:45 AM, but there was no answer, a voice mail was left requesting a return call. CNA D did not return call prior to exiting the facility. During an interview on 9/4/24 at 10:17 AM, LVN C said she remembered the incident in March 2024, and Resident #3 reached over to get snacks off her bedside table while CNA D was rolling her over during incontinent care. LVN C said Resident #3 was a very heavy-set lady. LVN C said CNA D was performing Resident #3's incontinent care by herself. LVN C said Resident #3 should have been a two person assist for safety, but CNA D was doing it by herself. LVN C said she did not know CNA D was even down there and CNA D did not ask her for help. LVN C said CNA D should have asked for help to ensure Resident #3's safety. LVN C said CNA D said she tried to catch Resident #3 but could not catch her in time. LVN D said CNA D was rolling her away from her and Resident #3 was a large resident and Resident #3 just kept going and rolled off the bed and into the floor. LVN C said she sent Resident #3 to the emergency room and Resident #3 received stitches to the inside of her mouth. LVN C said she asked CNA D why she did Resident #3's incontinent care by herself, and CNA D told her she thought she could do it. During an interview on 9/4/24 at 1:22 PM, CNA H said Resident #3 took two to three staff for incontinent care. CNA H said Resident #3 was a big lady. CNA H said it was not safe for one person to perform Resident #3's incontinent care because Resident #3 could roll out of the bed. During an interview on 9/4/24 beginning at 1:57 PM, the ADON said, unfortunately, CNA D was not following Resident #3's care plan. The ADON said Resident #3 required two people for incontinent care and CNA D was performing incontinent care by herself. The ADON said she would not change Resident #3 by herself because of Resident #3's size and Resident #3 was flaccid (unable to move) on her right side. The ADON said unfortunately there happens to be one aide more often than she would like, but there were always two nurses, and the nurses were instructed to assist the aides. During an interview on 9/4/24 beginning at 2:33 PM, the DON said Resident #3 was impulsive and she believed Resident #3 was a one person assist in March of 2024. The DON said as part of their updated interventions following Resident #3's fall, she was a two person assist now. The DON said she did not know if she could look back and see if Resident #3 was a one or two person assist in March of 2024. The DON said CNA D had rolled resident onto her right side and Resident #3 reached for something on her bedside table. The DON said CNA D tried to catch Resident #3 but could not and Resident #3 rolled onto the floor. The DON said Resident #3 was assessed and sent to the emergency room , where she received stitches to her lip. During an interview on 9/4/24 beginning at 3:10 PM, the ADM said she became the ADM in April of 2024 after the incident with Resident #3 on 3/26/24. The ADM said she was not the ADM when Resident #3 fell out of the bed during incontinent care, but she would expect staff to follow the proper procedures for providing care safely. Record review of the facility's form titled Certified Nurse Aide Orientation Packet with a start date of 1/10/24 indicated CNA D completed her Returned Demonstrated Clinical Skills on 1/22/24 with a pass rate on all skills including incontinent care, resident transfers/safe handling, and fall prevention. 2. Record review of an undated face sheet indicated Resident #5 was a [AGE] year-old male that admitted to the facility on [DATE] and discharged [DATE] with the diagnoses of schizoaffective disorder (mental health condition including schizophrenia and mood disorder symptoms), hemiplegia (paralysis of one side of the body), and BPH (Age-associated prostate gland enlargement that can cause urination difficulty). Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 00 which indicated severe cognitive impairment. The MDS also indicated Resident #5 was dependent for ADLs such as toileting, hygiene, bathing, bed mobility, transfer, dressing and personal hygiene. Record review of Resident #5's care plan dated 1/30/2024 titled 'Self Care' revealed Resident #5's goal was to be transferred by 2 staff members with the mechanical lift to maintain safety. Record review of incident and accidents from 01/01/2024 to 09/04/2024 showed no accidents related to mechanical lift transfers. During an interview and record review on 8/29/2024 at 10:00 AM, Resident #5's family member stated she had video of Resident #5 being transferred with just one CNA on multiple occasions. She stated she reported it to the ADM each time it occurred and nothing changed. Review of the video dated 5/19/2024 at 11:10 AM, revealed CNA F transferring Resident #5 from his bed to his chair using a mechanical lift by herself. During an interview on 9/03/2024 at 1:20 PM, CNA F stated there had been times in the past that she had no choice but to transfer residents with one person using a mechanical lift. She stated you cannot stop others from doing their work to come help you with every single transfer. She stated she now primarily worked the 300 hall and there were not too many residents requiring mechanical lifts for transfer, so she had not run into the issue of having to transfer someone by herself. She stated she now will ask therapy to help her when she does a mechanical lift transfer. CNA F stated she did not recall transferring Resident #5 on that day without help, but it was possible that she had. She had no recollection of any specific in service training on mechanical lift transfers. During an interview on 9/04/2024 at 1:30 PM, CNA H stated she transferred people alone with a mechanical lift every day. She stated there were 9 residents on hall 100 that required a mechanical lift to be used for transfer. CNA H stated there was no way one could get a CNA from another hall to stop what they were doing and come spot you 9 times to get them up and 9 times to put them back down. CNA H stated sometimes therapy had not minded helping, but she was told no by most of the nurses when she asked for assistance. She stated she has told the DON, ADM, and ADON numerous time and they told her to do the best she could. CNA H stated she understood that 2 people should be present with mechanical lift transfers for the safety of the resident and incase anything malfunctioned. During an interview on 9/04/2024 at 2:00 PM, LVN G stated she was aware there were times CNAs were left with no choice but to transfer residents by mechanical lift on their own. LVN G stated she and all the staff were aware it was a requirement for safety to have 2 people when using a mechanical lift. She stated anytime anyone of the CNAs asked her for help she helped, but there were times when she had to tell them she could help in an hour but not immediately. She stated the nurses had responsibilities that limited the amount of time they were able to do extra care for the residents. LVN G stated during the night shift everyone had to help everyone out to get all their jobs accomplished and keep the residents cared for. LVN G stated she felt they worked well as a team and were able to get all their duties done and the residents were cared for. During an interview on 9/04/2024 at 2:30 PM, the DON stated it was the policy of the facility to have 2 staff members present during a mechanical lift transfer for safety. The DON stated it had not been brought to her attention that the CNAs were unable to get help or help one another when performing a mechanical lift transfer. She stated she was unaware that Resident #5 had been transferred with only one staff member. The DON stated day shift has the most staff and there was no excuse for Resident #5 to have been transferred unsafely. The DON stated she was responsible for training and monitoring safe transfers. She stated she educated at least annually and as needed on safety of transfer. During an interview on 9/04/2024 at 3:30 PM, the ADM stated the facility was staffed for the acuity of the residents and the number of residents. She stated during the day there were department heads that included the DON, ADON, and MDS Nurse that could be asked to assist with mechanical lift transfers. The ADM stated therapy was always willing to help with these transfers, as well. The ADM stated Resident #5's family was very active in his care while he was there and had not mentioned a concern about him being transferred with one staff member. The ADM stated if Resident #5 was care planned to be a 2-person transfer and the staff was using a mechanical lift to transfer him, then it was unacceptable to transfer him alone. The ADM stated bruising, skin tears, and even more serious injuries like falling and fractures could occur from an improper transfer. On 9/4/24 at 3:40 PM, requested a policy on accidents and hazards or repositioning residents during incontinent care from the ADM. On 9/4/24 at 4:30 PM, the ADM said they did not have a policy on accidents and hazards or repositioning residents during incontinent care. The ADM provided a policy on Perineal care that did not address the positioning of the resident during the care. Review of FDA 'Guidelines to Hoyer Transfer', retrieved 6/10/2024 at 3:45 PM, https://www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf, indicated, . the safest practice for Hoyer transfers was to use 2 people. One person was required to operate the machine and the other assists and guarded the patient against injury. In instances of negligent operation, the machine may tip over with the resident in it or a loop on the sling may dislodge from the machine causing the resident to fall to the floor. The second person is there to prevent serious injury to the resident. Residents sometimes become agitated, and a second person should be there to help stabilize the sling. The battery may also lose power during a transfer. A second person could go get another battery while the first person stays with the resident . Review of an undated facility policy titled Hydraulic Lift revealed . the goals of using a hydraulic lift are .1. The resident will achieve safe transfer to bed or chair via a mechanical lift device. 2. The caregiver will demonstrate and correct transfer of the resident to the bed or chair via the hydraulic lift. 3. The resident will verbalize a decrease in anxiety following explanation of the procedure .

Based on interview and record review the facility failed to provide care in accordance with resident's comprehensive assessment and failed to ensure resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 of 11 residents reviewed for quality of care. (Resident #1) The facility did not monitor the condition of Resident #1's right foot when a CNA reported the resident's foot looked discolored. Resident #1 developed gangrene (the death of body tissue due to a lack of blood flow or a serious bacterial infection) in three of his right toes. On 4/18/22 the resident was admitted to the hospital and had his right leg removed above his knee. An Immediate Jeopardy (IJ) was identified on 04/29/2022. While the IJ was removed on 4/30/2022, the facility remained out of compliance at a scope of isolation and severity level of actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective plan. These failures could place residents at risk for failing to obtain their highest practicable physical and mental well-being and place them at risk for serious harm, hospitalization , or death. Findings included: Review of Resident #1's face sheet, with a print date of 4/29/22, indicated he was admitted on [DATE] and was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's care plan, with a print date of 4/29/22, indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin breakdown (at risk for/actual) related to history of cardiovascular disease, with interventions including inspect skin complete body head to toe every week and document the results. As well as monitor nutritional intake, weight, lab values, report significant changes to physician. Review of Resident #1's quarterly MDS dated [DATE] indicated he had minimal hearing difficulty, unclear speech, usually understood others and was usually understood. He had moderately impaired cognition, fluctuating inattention, and continuous disorganized thinking. He required the set-up help of two staff members with dressing and personal hygiene and used a wheelchair for mobility. The MDS did not address his rejection of care or verbal behaviors. Review of a skin data form dated 4/7/22, completed by LPN A, indicated Resident #1's skin color was normal, he had no rash/redness, no wounds, and no other skin issues. Review of skin assessments for Resident #1 indicated he had no skin assessment performed on 4/14/22 with no documented refusal or reason for it not being conducted. Review of a Results List (a printed form of the CNA's computerized ADL charting) with a print date of 4/29/22 indicated CNA B documented on 4/9/22 at 9:35 p.m. that Resident #1 was sitting in the front lobby with his shoe off. She noted there was redness and discomfort to his foot and that she notified the nurse. Another note on 4/9/22 at 9:37 p.m. indicated the resident refused the ADL of bathing and CNA B indicated the resident refused staff assistance. The resident's aides described him as having no skin issues or having no skin issues identified on 4/8/22, most of the day on 4/9/22, 4/10/22, 4/11/22, 4/12/22, 4/13/22, 4/14/22 and 4/16/22. On 4/15/22 and 4/17/22 the resident was marked as refused for skin observation. Review of a nurse's note completed by LVN C on 4/13/22 at 3:25 a.m. indicated Resident #1 had a skin issue to his right foot on 4/9/22 but had no skin issues on 4/13/22. Review of nurse's notes between 4/9/22 through 4/13/22 and 4/14/22 to 4/17/22 did not indicate any skin issues identified to Resident #1's right foot. Review of a nurse's note completed by LVN D on 4/18/22 at 1:07 p.m. indicated CNA E was giving Resident #1 a shower when she observed the resident's right foot to be dark red/purple. She then called for the nurse. LVN D observed that the discoloration to the resident's foot extended above the ankle and noticed black tissue covering the tops of the 2nd, 3rd, and 4th toes. The resident's hospice provider was called to come in and evaluate the resident. The hospice nurse came to the facility to assess the resident and gave new orders to send him to the ER for evaluation. Review of Resident #1's hospital notes from his 4/18/22 admission indicate he had black toes and a purple discoloration to his foot. The resident's family member indicated she had seen his foot roughly one week before, and it had not looked that way. The hospital notes indicate the resident had cyanosis (a bluish or grayish color of the skin) of his right lower extremity, black 2nd-4th toes, was cool to the touch and had no pulses. The vascular surgeon felt the resident had a chronic aortic occlusion (long [MEDICATION(S)] blockage in the aorta) which eventually led to gangrenous changes of his foot and irreversible ischemia (reduced blood flow) of his entire foot and lower leg. During an interview and observation on 4/26/22 at 11:45 a.m. Resident #1 was laying in his bed, eating his lunch. He seemed confused and said he had surgery on his leg recently because it hurt and did not know of any other reason for the surgery. He had a gauze bandage over the remainder of his leg. The dressing appeared clean, dry, and intact. During a phone interview on 4/27/22 at 1:50 p.m. Resident #1's family member said she saw the resident's foot somewhere between 4/1/22 and 4/18/22 and it did not look like it did when he went to the hospital. During an interview on 4/28/22 at 11:28 a.m. LVN A said she was a PRN employee. She said sometimes the staff nurses did resident skin assessments and sometimes the treatment nurse would. She Resident #1 would sometimes refuse care, baths, showers, etc. She said she didn't remember if she looked at his feet during the skin assessment she performed because he could get mean, cussed, and fought staff when they tried to look at him or touch him. She said she didn't remember any other skin issues he had though. During an interview on 4/28/22 at 8:28 a.m., CNA B said she noted on 4/9/22 that Resident #1 was sitting up by the nurse's station which was odd for him. She said she noticed his foot and toes looked very red, almost purple, and he kept taking off his house shoe to rub his foot. She said she notified LVN H that night, but she did not know what the nurse did after that. She said she did not remember if she notified her relief that next morning (4/10/22) at shift change, since it had been a few weeks since this incident occurred. She said she went on to chart, after her initial documentation of a skin issue, that he did not have any skin issues because the aides did not have to keep charting about the issues they found once they reported those issues to the nurse. She said the resident was more independent at that point and could do more for himself like take off his shoes and put socks on. She said she never smelled any foul odors when she provided care to him. During a phone interview on 4/28/22 at 1:44 P.M. LVN C said Resident #1 was a very private man and she went to check on him on 4/9/22. She said she asked him if anything was wrong with his foot and he said no. She asked him if she could look at his foot and he said no. She said they have ADL alerts which are triggered by a CNA clicking something is out of the ordinary with the resident. She said that they were supposed to finish answering the alerts by the end of the shift that the alert occurred on but sometimes the alerts would get backed up, so sometimes she would answer the alerts when she had a little down time on her shift. She said the alert about Resident #1 was one she happened to see on 4/13/22 and so she answered it for 4/9/22. She said she charted there were no issues with the resident because he said there was nothing wrong with him, but she should've charted that he refused. She said he refused care and showers and was a private man. She said anytime she would ask him if anything was wrong, he'd say no. She said he could speak and was fairly oriented. She said she was never notified directly by staff of his foot, only by the ADL alert she answered. She said she did not ask him about his foot until the 13th when she saw the ADL alert. She said did not put it on the 24-hour report or follow up on it afterwards. She said she did not follow up on it because he said he was ok. She said she did not work the night of 4/9/22, it was her weekend off and LVN H would have been working that weekend. During a phone interview on 4/29/22 at 9:20 a.m. LVN H said she was PRN and did not work all the time. She said she did work on 4/9/22 but worked 6 a.m. to 6 p.m. that day. She said Resident #1 was very combative and refused everything. She said he would fight with staff and cuss at them. She said she didn't remember what day she was notified by a CNA, but that a CNA told her that something looked wrong with the resident's foot. She said she went to his room and asked him to look at his foot. She said he told her no and she left the room. She said she went to his room a little while later and asked him again to look at his foot. She said he told her [OBSCENITY] no! and she again left his room. She said she went back again for a third time and asked him to look at his foot. She said he did not say anything and just looked at her. She said she did not chart anything about this because as she left his room, a self-toileting resident in the room next to his was covered in feces and she had to clean that resident up. She said it took her probably about an hour to clean that resident up and she forgot to chart anything about Resident #1's supposed skin issue or refusal to assess him. She said she did not recall who her relief was that night, and she did not believe she told them about what the CNA had reported. During an interview on 4/27/22 at 2:23 p.m. LVN D said she was a PRN (as needed) employee and worked only when she was needed. She said she had worked with Resident #1 maybe the week before she was notified of the discoloration to his foot, and his foot had not looked like that. She said on 4/18/22 there was a red discoloration to the resident's foot going up to his ankle, and his 3 middle toes were black with a foul smell. She said he usually wore a sock and a shoe, and he was noncompliant with showering. She said she had previously had to call his family to have them convince him to get a shower. She said she was not told by anyone that the resident had any issues with his right foot. She said sometimes the nurses on the floor completed the resident skin assessments and sometimes the treatment nurse did. She said she called the resident's hospice provider on 4/18/22 and the hospice nurse came out to look at the resident's foot. The hospice nurse contacted the resident's family about his foot and the resident's family requested he be sent to the ER. She did not know of any treatments they were doing for his right foot before this event occurred. She said the aide that came to get her was CNA E. During an interview on 4/28/22 at 11:42 a.m. CNA E said she went and got LVN D when she saw Resident #1's foot as she was getting him ready for a shower on 4/18/22. She said LVN D told her to go get the staffing coordinator and the nurse practitioner. CNA E said she, the staffing coordinator and LVN D got the resident into the shower chair because he was weak. She said the resident's toes were like a purplish/blueish color like he didn't have any circulation to his toes. She said his third toe looked dead, like it was going to fall off. She said the NP checked his feet and told LVN D to call the resident's hospice provider. She said CNA G was the aide that normally worked on the resident's hall and CNA G told her that she'd been telling them something was wrong with his foot. She was not sure who them was. She said CNA G told her the resident had been refusing his showers and they'd been having to call his family member to encourage him to shower. She said on 4/19/22 she and CNA G worked together, and she asked CNA G, did you hear about Resident #1? and CNA G said, yeah, I've been telling them about his foot. CNA E said she usually worked the other side of the hall Resident #1 lived on and she did not usually work with him. She said she had not been told anything about his right foot at all before this incident occurred. She said she smelled a strong odor of urine and saw urine on his floor in his room. She said she told the staffing coordinator that the resident smelled of urine and had urine on the floor of his room. She said the staffing coordinator was then able to convince the resident to shower. CNA E said when she entered the resident's room, he had his foot under the covers but did not have a sock or shoe on. When he uncovered his foot, she was able to see his foot looked bad. She said she did not smell anything when he pulled the cover off his foot. She said when she asked him in the shower if he was in pain, he did a hand motion of so/so and didn't say anything else. During an interview on 4/28/22 at 11:11 a.m. the staffing coordinator said Resident #1 often refused care. She said CNA E had come to her on 4/18/22 to let her know the resident was refusing to shower. She said she went in his room to ask the resident to please get a shower. CNA E then came and got her again for help to get the resident undressed and into the shower chair. She said she had never been told by hospice that he refused care from them. She said they had frequently needed to call the resident's family member to try and encourage the resident to get a shower but even she had trouble getting him to do it. During a phone interview on 4/28/22 at 1:00 p.m. the nurse case manager with Resident #1's hospice provider said the hospice RN saw the resident on 4/13/22 and documented his skin looked fine and no issues were noted. She said the hospice RN marked that there were no wounds noted to his foot and he had noted pulses. On 4/18/22 the hospice RN went to see the resident and notified the doctor and family of his foot being discolored. The family requested aggressive treatment and they sent the resident to the ER. She said the resident refused all aide services and bathing and the aide services had stopped seeing him. The case manager said the hospice RN charted on 4/18/22 that the resident's foot was cool to touch, and she could not feel any pulses. During a phone interview on 4/28/22 at 1:10 p.m. the NP said on 4/18/22 the aide came to her and told her Resident #1's foot was dark. She said his right foot, 2-4th digits were necrotic (dead tissue). She said she believed he had [CONDITION(S)] (an infection of the bone) and she had the nurse call the resident's hospice provider. She said this was the first time that she was ever aware of the skin issues he had, and she was never notified of it. She said when she came back to the facility after having the weekend off, she found out he had been hospitalized and had an amputation. She said she checked the 24-hour report every day she went to the facility and checked to see if there were any changes with the residents. She said did not see any mention of the resident's foot having any issues. She said she was unsure if the hospice nurse that visited him on 4/13/22 looked at his foot or not. She said if she knew about it before that day, she would have had the nurse notify the family and send him to the ER. During a phone interview on 4/28/22 at 1:23 p.m. the hospice RN said she did not know of Resident #1 refusing showers because he had stopped having the aides come before she started with the company at the end of January. She said she had previously had some issues with him such as to assess him while he was still sleeping or tired, he would get irritated and pull away from her. She said she saw him on Wednesdays, and she visited him on 4/13/22. She said when she saw him on the 13th, she noted his blood pressure was up while he was eating breakfast. She said he was a little cranky that day and she told the facility nurse his blood pressure was elevated and would need his blood pressure pill. She said he usually had a sock on and a house shoe unless he was lying in bed. She said when she was told about his foot being discolored by staff on 4/18/22 she asked them if they had known about this before now and they said no. She said she didn't think she observed his foot on 4/13/22, but she said he did allow her to feel for his pulse and she did find them. During an interview on 4/28/22 at 8:42 a.m. CNA J said Resident #1 could be combative and would refuse care. She said she was unable to look at his skin when she cared for him and could not look at his feet. She said she was never told anything was wrong with his foot and did not know he had been sent to the hospital until she came back from her weekend off. She said the only thing she ever smelled when she cared for him was the strong odor of urine, but never any smells of dying flesh. She said she marked that he had no skin issues because she was unable to look at his skin. During a phone interview on 4/27/22 at 3:20 p.m. CNA F said he took care of Resident #1 in the days before his discharge to have his leg amputated. He said he looked at the resident's body, but not at his feet. He said he never had to change the resident's clothes because he did it for himself. He said other times the resident would refuse skin observation. He said he noticed the resident was laying in the bed more often than he usually did and CNA G noticed he was laying in the bed more frequently as well. He said he was never aware of the resident's foot hurting or anything being wrong with it. He said the resident did not like to take showers and staff had only been able to convince him to have maybe 2 showers on his shift (6 a.m. to 2 p.m.) and they had to call his family member to convince him to take those showers. He said he never noticed any kind of drainage on the resident's sock and the only smell he noted was the resident's body odor from not bathing in a while. During an interview on 4/28/22 at 12:40 p.m. CNA G said she told several people about Resident #1 laying around, although he was still refusing his showers which was normal but was also refusing to smoke which was not normal for him. She said several people went to talk to him and see what was wrong with him. She said when the staff members that had attempted to speak with him told her of the conversation, they'd say he just refused to talk (she did not give any names of staff only departments such as therapy or nurses) She said he was very belligerent and would cuss at staff and try to fight them. She said staff members literally begged him to get a shower or to get close enough to him to shave him, but he refused. She said on 4/16/22 she was able to look at his back and chest when she looked in on him in the bathroom. She said he was not wearing a shirt and he slammed the door in her face. She then charted in her ADLs that his skin was fine because she had seen his torso. She said the more questions someone asked him the more he would get upset. She said when she asked him why he was laying around all the time and not smoking, he would shrug his shoulders and say he didn't want to. She said if a resident had a skin issue, she would continue to document about the issue even after she reported it to her nurse. She said she had spoken with the resident's hospice provider to see if they could get him to shower but he was also rude to hospice staff and they told her they couldn't make him do anything either. She said she never saw him act like he was in pain or that he was uncomfortable due to his foot. She said she never smelled any foul odors other than the strong smell of urine. During an interview on 4/28/22 at 10:45 a.m. the regional nurse said Resident #1 refused everything. She said he had been seeing the wound care physician, the nurse practitioner and hospice, but he refused everything. She said CNAs were told to look for bruising, blisters and so on, on the resident's skin. She said she would look at the charting where the aide found an issue with the resident's foot on 4/9/22 and where the nurse charted about it on 4/13/22. She said the reason he may not have had a skin assessment after 4/7 was because he refused, and she would investigate that as well. She again said he refused everything, and he'd been that way his whole life from her understanding. She said he would only let staff do things for him on his time and when he wanted it done. She said the wound care nurse may be able to see why he did not have a skin assessment after 4/7 until his return on 4/24. She said it was his right to refuse care and showers. During an interview on 4/28/22 at 12:03 p.m. the treatment nurse said she was made aware of Resident #1's foot the day he was sent out. She said the nurses were supposed to do his skin assessment and if they identified a wound, they were to let her know so she could take over his wound care and his skin assessments until the wound was healed. She said he was not seeing the wound care physician at that time and was unaware of any time he had. She said from now on she would be taking over skin assessments of residents and would be starting a skin sweep today, 4/28/22. She said CNA E had gotten her on 4/18/22 to have her look at the resident's toes. She said she got her gloves on and started touching his toes and he denied any pain. She said the top of his second, third and fourth toes were black. She said his foot was a light purple color and she could tell his circulation was poor and his foot was cold to the touch. His leg was dry but that was all she noted. She said if she had been notified of his foot before this event, she would have notified hospice immediately. During an interview at 1:00 p.m. on 4/29/22 the DON said since she did not know any of this was occurring with Resident #1, they did not do a QAPI meeting about it. She said her expectation of the staff would report any issues that they identify. She said they had already started educating their staff on reporting issues and that the CNAs should report issues to their nurses and the nurses should report to the families, the doctor/NP, the DON, etc. She said the staff should not document that there were no skin issues with residents if they do not actually see the resident's skin. An Overview of Wound Care policy with an effective date of July 2018 indicated: .Wounds can cause a person a lot of pain, an increased susceptibility to infection, scarring, increased nutritional needs, and anxiety . .Monitoring Staff should remain alert to potential changes in the skin condition and should evaluate, report and document changes as soon as identified. For example, a resident's complaint about pain or burning at a site where there has been pressure or observation during the resident's bath that there is a change in skin condition should be reported so that the resident may be evaluated further . .Many clinicians recommend evaluating skin condition (skin color, moisture, temperature, integrity, and turgor) at least weekly, or more often if indicated . .Document in the appropriate areas of the EMR on a consistent schedule. Areas include skin data collection modules, wound assessment modules, infection control modules, Care Plans, Nurses' Notes, scanned documents, and physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] The DON was notified on 4/29/22 at 12:06 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The DON was provided the Immediate Jeopardy template on 4/29/22 at 12:06 p.m. The facility's Plan of Removal was accepted on 4/29/22 at 5:49 p.m. and included: PROBLEM: Failure to follow-up on identified concern with patients skin integrity. ACTION: All residents have had a complete head to toe skin assessment completed with no unidentified skin issues found. PERSON RESPONSIBLE: Treatment Nurse AOC: 4-29-22 ACTION: All nurses to be educated by DON/ADON prior to their next shift on the importance of thorough assessment of skin integrity following any report of a concern. Verbal education and hand-outs will be utilized. ACTION: All nurses will be educated verbally by DON / ADON prior to their next shift on importance of documenting assessments & refusal of care in nurses notes. This education will include explaining need for assessment to patient with potential complications of refusal of assessment. Additionally, involve any family members or staff who may can assist in getting patient to comply with assessment. ACTION: All nurses will be educated verbally by DON / ADON prior to their next shift on importance of prompt notification of DON & documentation on 24 hour report if patient refuses skin assessment. ACTION: All nurses will be educated verbally by DON / ADON prior to their next shift on importance of notifying physician if patient has refused an assessment with potential negative impact on residents condition. PERSON RESPONSIBLE: DON/ADON/designee AOC: 4-29-22 ongoing ACTION: Facility will monitor compliance during morning meeting to include review & prompt clearing of ADL alerts, nursing notes, and shift report. ACTION: Results will be reported to QAPI monthly x 3 months to ensure on-going compliance PERSON RESPONSIBLE: Administrator/DON AOC: 4-29-22 Ongoing On 4/30/22 the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: An undated nursing management responsibilities form indicates .WOUND CARE NURSE .a. Weekly skin assessments and treatments/eTAR - monitor sample from each hall for compliance . During an interview on 4/29/22 at 12:30 p.m. the treatment nurse said she performed skin assessments yesterday on 20 residents and found no major skin issues with any resident. Record review of the skin assessments for all 20 residents involved in the treatment nurse's skin sweep indicated the treatment nurse did not identify any major skin issues. Record review of the in-service regarding the treatment nurse assuming the responsibility of all weekly skin assessments for all residents. The treatment nurse signed that she had been educated and assumed responsibility. During an interview on 4/29/22 at 2:55 p.m. the regional nurse said staff will ensure in the morning meetings that all ADL alerts will be cleared out and answered. During an interview on 4/30/22 at 10:30 a.m. LPN K said she was in-serviced on skin assessments and if she identified an issue, she had to notify the DON, family, the doctor, and the administrator (if the DON is not available). She said she was also educated on needing to document everything that they find and be specific, such as saying 2cm x 2cm skin breakdown was noted to her buttocks instead of a spot was noted on her butt. She said they were to assess the residents when they arrive and make sure to look them over and notify everyone that is involved in their care. She said if the resident refused care, they were to notify the physician and DON, put it on the 24-hour report and let the oncoming shift know and let the treatment nurse know so she could assess them. She said in the event she was told by her CNA that something was wrong with a resident's skin, she should assess the resident with the CNA, document about it, notify the physician, family, DON, and the oncoming shift. She said if the resident denies letting her look at his/her foot and denies anything was wrong, she should document this, notify the DON, and notify his/her family to see if they could possibly get him/her to allow them to assess. She said if she saw an ADL alert regarding a skin issue from a few days ago, she would need to see if there was any documentation about this skin issue and if there was not, she should assess it herself. During an interview on 4/30/22 at 11:03 a.m. CNA E said she was in-serviced on notifying the charge nurse and notating about any changes they saw with residents in their ADLs. She said they also were encouraged to write down what they saw and put it under the DON and treatment nurse's doors in the event the DON and treatment nurse were not in the facility. Record review of a Proper procedure for follow-up and reporting skin issues in-service with 9 nurse's signatures indicating they were in-serviced regarding communication, basic nursing skills, skin, and wound care, and change in condition. During an interview on 4/30/22 at 11:28 a.m. CNA G said she was in-serviced on resident assessments and to notify her charge nurse on any issues even if it's just a scratch. They are also to notate it in their ADL assessments on the resident. She said in the event she found a skin issue; she should notify her charge nurse and document the skin issue she identified. During an interview on 4/29/22 at 11:56 a.m. CNA L said she was in-serviced that morning about resident skin assessments. She said if she identified any skin issues, she was supposed to notify the DON, the treatment nurse, and the charge nurse. She said she was supposed to document any resident skin issues she identified in her ADLs and notes. She said she usually got the treatment nurse when she identified a skin issue with the resident but if she was not there, then she would notify her charge nurse. She said if there was a resident that refused showers, she would document that on a shower sheet and she will give it to the charge nurse and DON. She said in the event she needed to look at someone's skin that possibly had an issue, and they refused, she would go get the nurse to try and look at the resident instead. During an interview on 4/30/22 at 12:07 p.m. LVN M said she was in-serviced this morning and was educated to update the 24-hour report with current information and give an accurate shift change report. She said the treatment nurse had taken over all resident skin assessments. She said the staff nurses still did the weekend treatments for the residents as the treatment nurse did not work on weekends. She said if she saw a skin issue, she would assess it, document it and call the NP/physician, and the family, as well as let the oncoming shift know. She said in the event the resident was refusing to allow her to look at their skin, she would make sure to document it, notify the family and NP, and try to assess them more than once. She said she would also pass the refusal on to the next shift and put it on the 24-hour report. She said the importance of assessments and documentation was that small issues could turn into big issues later on; their licenses were on the line and that it's always important to notify the family because they may come in later and it could turn into a legal issue. During an interview on 4/30/22 at 12:24 p.m. CNA F said he was in-serviced on resident skin assessments. He said staff were to chart in their ADLs on any skin changes, notify the charge nurse, put it on a shower/skin sheet and give that sheet to the DON and the treatment nurse. He said he was to tell the DON and the charge nurse if a resident was refusing care/showers/skin observations. He said he would get other staff to attempt an assessment or observation in the event the resident refuses. During an interview on 4/30/22 at 12:29 p.m. CNA N said she was in-serviced on reporting skin issues and skin assessments to the charge nurse. She said if staff see any issues, they were to report it to the nurse. She said they were to chart any skin issues in their ADLs. She said she should report to the nurse if the resident refused to allow her to look at their skin. She said she would also tell the nurse and the DON and if the res [TRUNCATED]

Based on interview and record review the facility failed to promptly notify the physician of abnormal laboratory results for 2 of 2 residents receiving [MEDICATION(S)] and reviewed for laboratory services. (Residents #20 and #47) The facility did not notify the physician of Resident #47's high [MEDICATION(S)] level on 09/16/2021. The facility continued to administer [MEDICATION(S)] to Resident #47 until 10/08/2021 when the Resident's [MEDICATION(S)] level was at a critical high level (a laboratory result that is life threatening unless some action is taken in a very short time). The resident was sent to the hospital on 10/11/2021 and was admitted for [MEDICATION(S)] Toxicity (high levels of [MEDICATION(S)] that has become harmful). The facility did not promptly notify the physician of Resident #20's low [MEDICATION(S)] levels that were drawn on 08/18/2021, 09/20/2021, and 10/01/2021. The resident suffered a [CONDITION(S)] on 09/17/2021. The physician was not notified until 10/19/2021 of a low [MEDICATION(S)] level. This was determined to be past non-compliance that existed from 08/18/2021 and was corrected on 10/8/2021 due to the facility having implemented actions that corrected the non-compliance. This failure could place residents at risk for [CONDITION(S)], coma, injury, and death. Findings included: 1. Record review of face sheet and consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #47 sometimes understood others and was sometimes understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 00 which indicated severe cognitive impairment. The MDS indicated Resident #47 required limited to extensive assistance from staff for ADLs. The MDS indicated Resident #47 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a care plan dated 09/23/2021 indicated Resident #47 had a [CONDITION(S)] disorder and takes a routine anticonvulsant. The care plan indicated Resident #47 was prescribed [MEDICATION(S)] ([MEDICATION(S)]) with interventions to monitor for toxicity, observe for possible side effects, and report pertinent lab results to the physician. Record review of Doctors Lab reports provided by the facility indicated the following: 1. On 09/16/2021 a [MEDICATION(S)] ([MEDICATION(S)]) level of 32.3 (high). The normal range was 10 - 20 ug/ml. There was no indication of this level being reviewed by staff, reported to a physician or any new orders. 2. On 10/8/2021 results were received at 3:05 pm a [MEDICATION(S)] ([MEDICATION(S)]) level of 42.8 (critical high). There was a note that indicated, hold until Monday 10/11/2021 and please inform Nurse Practitioner B of any concerns. 3. On 10/11/2021 a [MEDICATION(S)] ([MEDICATION(S)]) level of 41.9 (Critical high). There was an acknowledgement by the ADON that indicated, send to the ER (emergency room ) to evaluate and treat. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record did not indicate any missed or held doses. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated on 10/08/2021 the 9:00 am dose was administered. All other doses through 10/11/2021, when the resident was transferred to the hospital, were not administered. Record review of nurse's notes dated 9/01/2021-10/11/2021 indicated the following: 1. 10/07/2021 - increased drowsiness and refusing to eat meals. Resident #47 was noted to have been staring at the ceiling. 2. 10/08/2021 - [MEDICATION(S)] dose held, pending results of level. 3. 10/10/2021 - resident having frequent episode of choking. Record review of hospital records dated 10/11/2021 indicated Resident #47 was admitted to the emergency department at 11:59 pm with a chief complaint of high [MEDICATION(S)] level and AMS (altered mental status). The history and physical indicated Resident #47 was sent to the hospital for a [MEDICATION(S)] level that was elevated to 42. This high level in combination with the patient's altered mental status for the past week prompted the nursing home to send her to the emergency department. Nursing home staff said Resident #47 has seemed lethargic lately and she has not been eating much food. At baseline she responds to her name and is able to answer simple questions; however, lately she has had garbled speech and has not been as responsive to her name as usual. The resident was admitted with telemetry (heart monitoring) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 10/12/2021 indicated, overnight nursing did report that the patient mental status was significantly impaired and after further investigation reveals this is simply due to [MEDICATION(S)] toxicity. A progress note dated 10/13/2021 indicated Patient still lethargic this morning. Yesterday patient was hypotensive (low blood pressure) despite being given fluid boluses and therefore had to be started on [MEDICATION(S)] drip (a medication to increase blood pressure). A progress note indicated, a [MEDICATION(S)] level that is 40 which I suspect is the cause of her altered mental status. A progress note dated 10/14/2021 indicated, patient was able to be weaned off of [MEDICATION(S)] drip (a medication to increase blood pressure) and maintain blood pressures .nursing reports that patient's mental status/consciousness has not improved. An assessment & plan dated 10/14/2021 indicated, Discussed with the family about the severity the patient and if/when patient's mental status returns, we will discuss about stopping the [MEDICATION(S)] completely and transition over to another anticonvulsant. 2. Record review of face sheet and consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were the following orders: 1. [MEDICATION(S)] ([MEDICATION(S)]) extended 100 mg capsule 1 capsule by mouth 2 times a day for convulsions, with a start date of 12/10/2020 and a discontinued date of 02/22/2021. 2. [MEDICATION(S)] ([MEDICATION(S)]) extended 100 mg capsule, 1 capsule 3 times a day for convulsion, with a start date of 02/22/2021 and discontinued date of 03/06/2021. 3. [MEDICATION(S)] ([MEDICATION(S)]) extended 100 mg capsule, 2 capsules by mouth 2 time per day for convulsion, with a start date of 03/06/2021 and a discontinued date of 10/19/2021. 4. [MEDICATION(S)] ([MEDICATION(S)]) extended 100 mg capsule, 2 capsules by mouth daily at bedtime give 2 capsules to equal 200 mg, with a start date of 10/19/2021. 5. [MEDICATION(S)] ([MEDICATION(S)]) extended 100 mg capsule, 3 capsules by mouth 1 time per day give 3 caps to equal 300 mg, with a start date of 10/19/2021. Record review of the MDS dated [DATE] indicated Resident #20 sometimes understood others and was usually understood. The MDS indicated a BIMS (brief interview for mental status) score of 00. This score indicated the resident had severely impaired cognition. The MDS indicated Resident #20 required limited to extensive assistance from staff for ADLs. The MDS did not indicate a [CONDITION(S)] disorder. Record review of a care plan dated 10/19/2021 indicated Resident #20 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan indicated the resident was mildly cognitively impaired. Record review of Doctors Lab reports provided by the facility indicated the following: 1. On 08/18/2021 a [MEDICATION(S)] ([MEDICATION(S)]) level of 7.2 (low). The normal range was 10 - 20 ug/ml. There was no indication of this level being reviewed by staff, reported to a physician or any new orders. 2. On 09/20/2021 a [MEDICATION(S)] ([MEDICATION(S)]) level of 7.4 (low). There was no indication of this level being reviewed by staff, reported to a physician or any new orders. 3. On 10/01/2021 a [MEDICATION(S)] ([MEDICATION(S)]) level of 9.4 (low). There was no indication of this level being reviewed by staff, reported to a physician or any new orders. 4. On 10/17/2021 a [MEDICATION(S)] ([MEDICATION(S)]) level of 7.9 (low). There was an acknowledgement by the ADON dated 10/19/2021 with notes to increase the [MEDICATION(S)] ([MEDICATION(S)]) dosage to 100 milligrams three times a day. Record review of the medication administration records dated 08/01/2021 - 10/18/2021 indicated [MEDICATION(S)] ([MEDICATION(S)]) 100 mg capsule, 2 capsules by mouth 2 times per day was administered. There was no indication of any further doses during this time frame. Record review of hospital records dated 09/17/2021 indicated Resident #20 was admitted to the emergency department at 12:53 am with a chief complaint of [CONDITION(S)] activity. Instructions from the emergency room physician indicated, continue all previous orders. Have the attending physician review the [MEDICATION(S)] and [MEDICATION(S)] levels when the [MEDICATION(S)] level has returned. They may make adjustments to the dosages. Record review of a progress note dated 09/17/2021 by Nurse Practitioner A indicated a follow up exam after Resident #20 was sent to the hospital due to [CONDITION(S)] activity. The progress note indicated a new order for a [MEDICATION(S)] level to be done on 09/20/2021. An interview on 10/15/2021 at 9:59 am the family member of Resident #47 revealed on 09/27/2021 she had requested the nurse contact the doctor because she was concerned about her mother having a high [MEDICATION(S)] level. She doesn't remember who she talked to. She said she had been taking care of her mother long enough she knew when her [MEDICATION(S)] level was high. She said her mother was not eating good and was not her usual self. She said her mother was currently in the hospital in a coma. An interview on 10/15/2021 at 11:55 am LVN E revealed when a resident is admitted the nurses fax a packet to the physician. She said once orders are received, the orders are entered into the computer. She said then a lab requisition would be filled out for it lab ordered and a copy put into the lab book. She said a lab person comes to the facility to collect the lab. She said when you fill in the lab requisition you put in the comments every 3 months. Then the lab knows to draw the lab every 3 months. She said once the results are received, they are faxed to the doctor, unless the lab is critical and then doctor is called. Once the doctor is notified the results are scanned into the electronic chart. She did not know who scanned in the results. She said there is also a website for Doctors Lab where you can review results. An interview on 10/15/2021 at 12:00 pm LVN G revealed once an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the nurse then fills out a lab requisition sheet and notifies the lab if it is a stat order. She said the lab requisitions are placed in the lab binder and put on the 24-hour report. She said lab staff comes to the facility Monday - Friday each week. They draw all the labs. Once results are received, they are reported to the doctor. Once any new orders are received from the doctor the results are placed in a basket in the medication room and the new orders are entered into the computer. She said she thinks the person that orders supplies scan the results in the computer. An interview on 10/15/2021 at 12:53 pm LVN H revealed once an order is received for a lab the nurse puts the order into the computer and saves it and submits it to the medication administration record. She said then a lab requisition is filled in and placed in the lab notebook. She said results are faxed to the facility from the lab each day or you can check online for results. She said whatever nurse on duty goes through the reports and notifies the doctor of the results. She said the lab calls the facility with any critical lab values. She said results are faxed to the doctor, unless the lab is at a critical level and then the doctor is called. The nurse then charts the doctor notification into the nurse's notes. The hard copy should then be signed by the receiving nurse and placed in a box in the medication room. An interview on 10/18/2021 at 10:52 am the DON revealed the ADON was responsible for reviewing the labs each day. She said she would have expected the elevated [MEDICATION(S)] level on 09/16/2021 to have been reported to Nurse Practitioner B. She said Nurse Practitioner B reviews all the labs. She said Nurse Practitioner B was out for a family emergency. She said she would have expected Resident #47's [MEDICATION(S)] to have been held after the high level on 09/16/2021. An interview on 10/18/2021 at 12:08 pm the ADON revealed she did not remember ever seeing the elevated [MEDICATION(S)] level on 09/16/2021. She said it was her handwriting on the urinalysis from the same day. She only remembers the urinalysis results. Normally all labs come across my desk. She said she had been the ADON position since August 2021 and she had been logging all of the labs all through the month of September. She said she prints labs from Doctor's Lab website and then sends them to Nurse Practitioner B. She said she then makes a note of any new orders from Nurse Practitioner B. She said she did not know how to do checks and balances to make sure all labs are reviewed. She said she now takes the yellow lab requisition slip from the lab book and checks the lab results on Doctors Lab website. She said if a lab is missed, she calls the lab. She said she was just educated on reconciling the lab requisition sheets, with orders and results last week (October 11, 2021 - October 15, 2021). She said as far as she knows she just missed Resident #47's high [MEDICATION(S)] level on 09/16/2021. She said should have notified Nurse Practitioner B and the [MEDICATION(S)] should have been held. She said she should have made a note on the lab results. An interview on 10/20/2021 at 8:45 am Nurse Practitioner A said she had not been aware of an elevated [MEDICATION(S)] level until after Resident #47's daughter called and made her aware. She said the daughter called on October 7, 2021 and this was when she ordered a stat [MEDICATION(S)] level. After the results were received Resident #47's [MEDICATION(S)] was held. She said the resident had symptoms of [MEDICATION(S)] toxicity. She said the resident had increased confusion, trouble eating, and difficulty swallowing. She said [MEDICATION(S)] toxicity can also cause a [CONDITION(S)]. She said Resident #47 had been having a steady decline and a urinary tract infection and could not say if her symptoms were due to [MEDICATION(S)] toxicity. She said Resident #47 began having vaginal bleeding before being transferred to the hospital. Nurse Practitioner A said when she came in the morning of October 11, 2021, she had another [MEDICATION(S)] level drawn from Resident #47. She said it was high and she sent her to the hospital. She said a low [MEDICATION(S)] level would put a resident at risk for increased seizures. She said the change she made on 10/19/2021 to Resident #20's [MEDICATION(S)] was the first change she had made lately. An interview on 10/20/2021 at 9:07 am the ADON revealed she does not remember seeing any low [MEDICATION(S)] levels for Resident #20. She said the lab only calls the facility concerning critical lab levels. She said she just missed Resident #20's low [MEDICATION(S)] level from 10/01/2021 and the low level was not reported to Nurse Practitioner B. She said when she first started being responsible for reviewing the labs in August or September, she was not reviewing them before she sent them to Nurse Practitioner B. She said last week she began paying closer attention to the labs to see what was low and what was high. She said her plan is to get the lab book each day and see what labs need to be reviewed and will fax the information to Nurse Practitioner B and chart every lab drawn that day. She said the 100% lab audit took place on 10/16/2021 & 10/17/2021. She said the Doctor's lab came into the facility on [DATE] to perform their own audit. She said she was not instructed until the week of 10/10/2021 to start reviewing the lab book. She said she had no trainings on how to review lab results before the week of 10/10/2021. An interview on 10/20/2021 at 9:20 am the DON revealed the first lab audit was completed on October 12, 2021 and October 13, 2021. She said there was a partial audit of 20 percent of the residents. She said the 100% lab audit was completed on 10/16/2021 and 10/17/2021. She said the ADON was responsible for reviewing the labs in August 2021 and September 2021. She said she was educated on the process when she began in August. She said it has always been the ADON's responsibility to review all labs. An interview on 10/20/2021 at 9:30 am the administrator revealed corporate completed the 20% lab audit. She said the low [MEDICATION(S)] level for Resident #20 was revealed from the 100% lab audit and a new level was checked on October 17, 2021 and the level was addressed in an appropriate time frame. An interview on 10/21/2021 at 10:05 am the attending physician said he was aware of Resident #47's high [MEDICATION(S)] level and she was sent to the hospital. He said he cannot remember specifically if he was ever notified of the high [MEDICATION(S)] level in September 2021. He said him being notified should be noted on the lab slip. He said [MEDICATION(S)] toxicity causes increased confusion and lethargy. He said he is familiar with Resident #20. He said he cannot remember being notified of any of Resident #20's low [MEDICATION(S)] levels. He said a low [MEDICATION(S)] level increases the risk for [CONDITION(S)]. An interview on 10/21/2021 at 10:39 am the administrator said she expects the current process just put into place to be followed. She said the orders should be sent to the lab. Once the results are received, the doctor should be notified and receive any new orders. She said the task of monitoring the labs should be assigned to one person. An interview on 10/21/2021 at 11:16 am Resident # 20 said she does remember having a recent [CONDITION(S)] but does not remember the date. A Mount [NAME] article titled [MEDICATION(S)] Overdose dated 12/03/2019, https://www.mountsinai.org/health-library/poison/[MEDICATION(S)]-overdose, indicated .The symptoms of a [MEDICATION(S)] overdose vary. They may include: coma, confusion, staggering gait or walk, unsteadiness, uncoordinated movements, involuntary, jerky, repeated movement of the eyeball, [CONDITION(S)], tremor, sleepiness, slow or slurred speech, lethargy, low blood pressure, nausea and vomiting, swollen gums slow or irregular heartbeat . A Drugs.com article titled [MEDICATION(S)] Toxicity last updated 10/04/2021, https://www.drugs.com/cg/[MEDICATION(S)]-toxicity.html, indicated .[MEDICATION(S)], or [MEDICATION(S)], toxicity happens when you have high levels of [MEDICATION(S)] in your body that become harmful. [MEDICATION(S)] is a medicine that is used to prevent and treat seizures. [MEDICATION(S)] toxicity can lead to a coma .What are the symptoms of [MEDICATION(S)] toxicity? fast, uncontrollable eye movements or double vision, dizziness, drowsiness, or confusion, lack of coordination of fingers, hands, arms, legs, or body, slurred speech, nausea or vomiting, decreased appetite, decreased activity, abdominal bloating, or irregular jerky movements in children or the elderly . A facility policy and procedure titled laboratory and Radiology Service Coordination date 02/12/2021 indicated, .upon completion of the testing and notification of results . notify physician of results .document physician notification . A Lab QAPI Plan with a beginning date of 10/08/201 indicated, .the DON or ADON will reconcile lab/Xray requisitions prior to morning clinical meeting and review confirmation lab draw and follow up notify the provider with results of diagnostic test and document on results and in electronic medical record to confirm provider notification . It was determined these failures placed Resident #20 and #47 in an Immediate Jeopardy situation from 08/18/2021 through 10/08/2021. The facility took the following actions to correct the non-compliance on 10/17/18: The DON in-serviced the ADON and nursing staff on notification of critical laboratory values and when to notify the physician. On 10/20/2021, the survey team determined interventions were completed by: The ADON was interviewed and said they received training (the week of 10/10/2021) prior to the investigators entrance regarding physician notification of critical laboratory values and when to notify the physician.

Based on observation, interview, and record review, the facility failed to ensure treatment and care in accordance with professional standards of practice was provided for 1 of 1 resident reviewed for quality of care. (Resident #1) The facility did not: *identify Resident #1 as at risk for [MEDICAL CONDITION] when she returned from the hospital with a [DIAGNOSES REDACTED]. *communicate Resident #1's medical history of [REDACTED]. *develop and implement a care plan with interventions to address Resident #1's history of [MEDICAL CONDITION] and urinary tract infections. *consult a urologist for Resident #1 per the hospital discharge recommendation. *obtain a KUB (x-ray of kidney, ureter, bladder which can detect [MEDICAL CONDITION]) and urinary analysis as ordered by healthcare providers for Resident #1. Resident #1 had a history of [REDACTED]. The resident was found unresponsive on 5/23/20 and admitted to the hospital with [REDACTED]. Resident #1 suffered [MEDICAL CONDITION], acute [MEDICAL CONDITION] and acute [MEDICAL CONDITION] requiring intubation (inserting a tube through the mouth into the airway). An Immediate Jeopardy (IJ) situation was identified on 6/10/20 at 3:52 p.m. While the IJ was removed on 6/11/20 at 3:50 p.m., the facility remained out of compliance at a severity level of actual harm and a scope of pattern, due to the facility's need to complete in-service training and evaluate the effectiveness of their plan of removal. Findings included: The physician order [REDACTED].#1 was [AGE] years old, admitted [DATE], readmitted [DATE] and had [DIAGNOSES REDACTED]. The report indicated an order for [REDACTED].#1 was to be administered 650 mg of Tylenol every 4 hours, as needed for pain or fever, via her PEG tube starting on 4/1/20. The summary did not indicate the resident had a Foley catheter. The MDS dated [DATE] indicated Resident #1 had unclear speech, was usually understood and understood others. The MDS indicated the resident had mild cognitive impairment and had fluctuations in disorganized thinking, required extensive assistance with bed mobility, toilet use, personal hygiene and bathing. The MDS indicated Resident #1 did not have an indwelling catheter or intermittent catheterization and was always incontinent of bowel and bladder. The MDS indicated the resident had received as needed pain medication and non-medication interventions for mild pain occasionally in the 5 day look back period. The MDS indicated Resident #1 received nutrition through a feeding tube and received 501cc/day or more of fluid intake via her feeding tube. The MDS indicated Resident #1 received antibiotics 4 days during the 7 day look back period. The care plan updated on 4/30/20 indicated Resident #1 had a urinary catheter. The care plan interventions included provide catheter care as ordered, monitor fluid intake/output and monitor urine appearance, amount, color, odor and clarity. The care plan did not address Resident #1 history of [MEDICAL CONDITION] or urinary tract infections. A hospital discharge summary dated 4/1/20 indicated Resident #1 had 2100 ml (the female urinary bladder can store up to 500 ml of urine and people feel the need to urinate when the bladder is between 200 and 350 ml) of urine drained from her bladder upon admission to the hospital on [DATE]. The summary indicated Resident #1 had acute [MEDICAL CONDITION] and recommended Resident #1 follow up with a urologist due to her acute [MEDICAL CONDITION]. A nursing note dated 4/1/20 at 9:36 p.m., written by LVN J indicated Resident #1 returned to the facility by ambulance at 6:30 p.m. The nursing note did not address Resident #1's [DIAGNOSES REDACTED]. She did not answer and the number indicated the voice mail was not set up to receive messages. The 24-hour report sheets (used to communicate nursing and medical information about a resident) dated 4/1/20 through 5/23/20 did not include Resident #1's history of [MEDICAL CONDITION]. The facility history and physical completed by the medical director on 4/4/20 indicated Resident #1's admitting [DIAGNOSES REDACTED]. The history and physical indicated Resident #1 had recently been sent to the hospital for fever and altered mental status and was found to have acute [MEDICAL CONDITION] and had a Foley catheter placed. A nursing note dated 4/30/20 indicated Resident #1's indwelling catheter was removed. The note did not address the reason for removing the indwelling catheter. The clinical record dated 4/1/20 through 4/30/20 for Resident #1 did not contain a physician order [REDACTED]. A nursing note dated 5/5/20 at 4:19 a.m., completed by RN C indicated Resident #1's abdomen was distended and firm when palpated. The note indicated Resident #1 voiced discomfort many times during the shift especially when incontinent care was provided. The note indicated Resident #1 had bowel sounds in all 4 quadrants (sections of the abdomen) and her bowels were moving with loose brown stools. During an interview on 6/10/20 at 11:25 a.m., RN C said she took care of Resident #1 often. She said Resident #1 reported abdominal pain approximately 1-2 times a week. She said Resident #1's pain was treated with Tylenol, a warm compress or position changes and the resident always reported pain relief. RN C said sometimes when Resident #1 complained, her abdomen was distended and at other times it was not. RN C said she thought the abdominal distention was gastrointestinal related. She said she never considered it was urinary tract related. She said she did not know about Resident #1's history of [MEDICAL CONDITION] and urinary tract infections. She said pertinent medical history was generally communicated on the 24-hour report sheet or in a verbal shift report. She said never received Resident #1's history of [MEDICAL CONDITION] or urinary tract infections in a verbal shift report. She said she was sure she reported Resident #1 was complaining of pain and had a firm and distended abdomen to the NP on 5/5/20, but must have forgotten to document it. A nursing note dated 5/5/20 at 2:31 p.m. completed by LVN D, indicated Resident #1 complained of lower abdominal pain and the NP was notified. The note indicated Resident #1 had bowel sounds in all 4 quadrants. A NP progress note dated 5/6/20 indicated nursing staff reported Resident #1 had abdominal firmness and tenderness to touch. The note indicated Resident #1 was lying in bed and was alert to person and place. The note indicated Resident #1 was able to verbalize her needs and stated her stomach felt tight. The note indicated Resident #1 reported she had a bowel movement on 5/5/20 but felt something was wrong. The note indicated the NP reviewed Resident #1's vital signs, laboratory test, diagnostic testing, nutrition, orders and history and physical. The progress note indicated Resident #1's abdomen was distended and bowel sounds were hypoactive (reduction in loudness, tone and regularity) in all four abdominal quadrants. The progress note indicated an abdominal x-ray was ordered for possible ileus (an obstruction of the intestine). A nursing note dated 5/6/20 at 12:33 p.m. completed by LVN D, indicated Resident #1 was seen by the NP and received a new order for an abdominal x-ray related to Resident #1's abdominal pain and distention. The note indicated the abdominal x-ray result was normal. During an interview on 6/9/20 at 4:15 p.m., LVN D said Resident #1 complained of lower abdominal pain approximately 2 times a week. LVN D said she administered Tylenol to Resident #1 when she complained of pain and the Tylenol was effective. She said the resident reported pain relief after having a bowel movement. She said she thought Resident #1's abdominal pain and distension was related to her gastrointestinal system. She said she called the NP on 5/5/20 and reported the resident was complaining of lower abdominal pain and the NP said she would see the resident the next day (5/6/20). She said the nurse practitioner ordered an abdominal x-ray on 5/6/20 and the results were normal. She said she called Resident #1's daughter the day the abdominal x-ray was ordered to let her know Resident #1 had abdominal pain and distension and the NP ordered an abdominal x-ray. LVN D said Resident #1's daughter mentioned the resident had a history of [REDACTED]. LVN D said she intended to notify the NP of the daughter reporting Resident #1 had a history of [REDACTED]. During an interview on 6/9/20 at 12:50 p.m., Resident #1's daughter said she received a call 5/6/20 from the facility at 9:34 a.m. to notify her Resident #1 had reported having abdominal pain and an x-ray had been ordered. Resident #1's daughter said she told the nurse Resident #1 had a history of [REDACTED]. The X-ray report dated 5/6/20 indicated a two-view abdominal x-ray was performed with the following result: Two-view abdomen: The gas pattern of the stomach, small bowel and colon are all normal. There is no obstruction, free air, or any other finding. IMPRESSION: Normal two-view abdomen. A nursing note dated 5/8/20 at 5:48 a.m., completed by RN C, indicated Resident #1's lower abdomen was hard and she was crying in pain. The note indicated the NP was notified and ordered a STAT (urgent) KUB, BMP (basic metabolic panel), and CBC (complete blood count). The physician order [REDACTED].#1 had an order for [REDACTED]. The clinical record dated 5/8/20 through 5/23/20 did not indicate the results of a KUB were received, reported to the NP, and followed up on by the facility. The 24 hour reports from 5/8/20-5/23/20 did not indicate the results of a KUB were pending, received, reported to the NP, and followed up on by the facility. A nursing note dated 5/8/20 at 2:45 p.m., completed by LVN A indicated Resident #1 had been in bed all day complaining of hardness in her abdomen. The note indicated Resident #1 reported having a bowel movement and the discomfort seemed to be subsiding. During an interview on 5/30/20 at 1:15 p.m., LVN A said she took care of Resident #1 on many occasions. She said Resident #1 was voiding after her indwelling catheter was removed on 4/30/20. LVN A said the CNAs kept track of Resident #1's voiding by the number of incontinent episodes per shift. She said she was surprised to hear Resident #1 had a lot of urine in her bladder at the hospital. She said when she palpated Resident #1's lower abdomen, at times she felt a hard area in her lower abdomen. LVN A said she thought it was a bowel issue because Resident #1 would report not having a bowel movement for a couple of days. She said Resident #1 was treated with [MEDICATION NAME] and stool softeners. LVN A said the wound care nurse usually followed up on residents' laboratory orders. During an interview on 6/9/20 at 5:00 p.m., LVN A said it never occurred to her Resident #1's pain may have been related to her bladder. She said she did not know Resident #1 had a history or [MEDICAL CONDITION] or urinary tract infections. LVN A said she would normally find out about important medical information and needed monitoring of residents from the 24 hour shift report. She said she never saw anything on the shift report about Resident #1 having a history of [MEDICAL CONDITION] or urinary tract infections. She said Resident #1 complained of abdominal pain 1-2 times per week. She said Resident #1's pain was relieved with Tylenol or after having a bowel movement. LVN A said she was working when the x-ray tech came to perform the KUB on 5/8/20, but she did not know if the results were received. She said she asked the NP about collecting a UA on 5/14/20 and received an order to collect a urine sample for a UA. LVN A said she tried to collect the urine via in and out catheter, but was unable to get a return of urine and did not attempt again. She said she reported to LVN F, the on-coming nurse a UA needed to be collected. LVN A said she must have forgotten to put Resident #1 needed a urine sample collected on the 24 hour report. She said she must have forgotten to document the in and out catheter attempt. During an interview on 6/10/20 at 10:40 a.m., LVN F said she did not remember being told Resident #1 needed a UA collected. She said Resident #1 never complained of abdominal pain to her and the resident's abdomen was always distended. LVN F said she was not aware of Resident #1's history of [MEDICAL CONDITION]. The physician order [REDACTED].#1 had an order for [REDACTED]. The clinical records dated 5/14/20 through 5/23/20 for Resident #1 did not contain a physician order [REDACTED]. The nursing notes dated 5/14/20 through 5/23/20 did not indicate an order for [REDACTED]. The 24-hour reports dated 5/14/20 through 5/23/20 for Resident #1 did not indicate there was an order for [REDACTED]. A nursing note dated 5/22/20 at 6:31 p.m., completed by LVN F indicated Resident #1 had a temperature of 100.2 degrees. The note indicated the on-call NP ordered a CBC, CMP, and a urinalysis with culture and sensitivity to be collected on the morning of 5/23/20. A nursing note dated 5/22/20 at 11:04 p.m., completed by LVN F indicated Resident #1 had a distended abdomen and one episode of vomiting while her temperature was elevated earlier in the shift. A nursing note dated 5/23/20 at 12:15 a.m., indicated Resident #1's abdomen was slightly distended. The note indicated the abdomen was soft and non-tender to the right upper quadrant, right lower quadrant, and the left upper quadrant. The note indicated there was a hard abdominal mass in the abdomen and the resident had a temperature of 99.1. The NP was notified and new orders for a chest x-ray and KUB later in the morning, Tylenol 650 mg for fever, check resident for impaction, and [MEDICATION NAME] suppository. The late entry nursing note dated 5/23/20 at 5:54 a.m., indicated at 12:40 a.m. Resident #1 was found with delayed respirations and was not rousable. The note indicated Resident #1 was having apneic episodes (temporary cessation of breathing), 911 was called and Resident #1 was transferred to the emergency room via EMS. A hospital emergency room visit note dated 5/23/20 indicated Resident #1 was hypotensive (had a low blood pressure of 89/51) and was minimally responsive. The note indicated Resident #1's laboratory work demonstrated possible urinary tract infection, acute kidney injury, and leukocytosis (an elevated amount of white blood cells in the blood). The note indicated Resident #1 had almost 2 liters (2000 ml) of urine output immediately after insertion of an indwelling catheter. A hospital history and physical dated 5/23/20 indicated Resident #1 was noted to have a very hard abdominal mass on arrival to the emergency room . The history and physical indicated the hard mass was gone after an indwelling catheter was placed and immediately drained over 2 liters of milky purulent (containing pus) urine. The hospital intensive care unit admission note dated 5/23/20 indicated Resident #1 was in septic shock secondary to a UTI. The note indicated Resident #1 had altered mental status secondary [MEDICAL CONDITION] from the UTI and suffered acute (abrupt onset) kidney failure. The note indicated Resident #1 had a history of [REDACTED]. The note indicated her creatinine was acutely elevated at 4.4 on admission to the hospital and supported the [DIAGNOSES REDACTED]. The note indicated Resident #1 had a distended bladder with approximately 2 liters of purulent urine immediately returned after indwelling catheter placement. The note indicated the physician suspected [MEDICAL CONDITION] (blockage of urine through the ureter, bladder, or urethra due to some type of obstruction). The hospital discharge summary dated 5/27/20 indicated Resident #1's discharge [DIAGNOSES REDACTED]. The discharge summary indicated Resident #1 was admitted for acute [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]ly due [MEDICAL CONDITION] from a urinary tract infection. The summary indicated Resident #1 was intubated, started on antibiotics and treated with medications to improve her low blood pressure. The summary indicated a urologist was consulted due to her severe [MEDICAL CONDITION] upon admission to the hospital. The urologist recommended Resident #1 keep a urinary catheter in place. During an interview on 6/9/20 at 12:40 p.m., Resident #1 was at a rehabilitation facility. She said she was urinating after her catheter was removed, but she could not remember if she had pain at the other facility. During an interview on 6/9/20 at 4:00 p.m., an unidentified CNA said Resident #1 had an indwelling catheter, but it was removed. The CNA said Resident #1 had wet briefs and said she never had to report to the nurse Resident #1 did not have a wet brief or did not have a bowel movement. The CNA said the last time she took care of Resident #1 on 5/23/20, the resident complained about abdominal pain and vomited. She said she was not sure how often Resident #1 complained of abdominal pain but said it was not daily. During an interview on 6/10/20 at 11:24 a.m., CNA I said she took care of Resident #1 often. She said the resident initially had a catheter but it was taken out. She said Resident #1 regularly voided and regularly had bowel movements when she took care of her. She said Resident #1 mentioned approximately twice a week she had abdominal pain and she always reported it to the nurse. During an interview on 5/30/20 at 5:28 p.m., LVN D said the treatment nurse or floor nurse were responsible for following up on laboratory work or tests ordered for residents. LVN D said if a laboratory or other test had been ordered and results had not been received she passed that on during shift report. During an interview on 5/30/20 at 5:21 p.m., RN C said she was the wound care nurse. She said she had been in the position of wound care nurse since 5/6/20. She said she was responsible for getting laboratory and x-ray results off the printer and faxing them to the physician or NP. She said she was not sure who's responsibility it was to follow up on laboratory tests for which no results had been received. RN C said if she was supposed to follow up on laboratory work or test for which results were not received she was never told it was part of her job. She said she remembered entering the order for a KUB on 5/8/20 in Resident #1's electronic health record. She said she did not know if the KUB was completed or if results were received. During an interview on 5/30/20 at 5:03 p.m., the medical director said a KUB might show bladder distension and urinary obstructions. During an interview on 6/10/20 at 12:21 p.m., the medical director said if abdominal pain and distention were reported to him he would typically order CBC, BMP, and UA. The medical director said he might also order an abdominal x-ray and have the resident checked for impaction. He said if a resident had recently been diagnosed with [REDACTED]. The medical director said there were many variables and depending on the resident's vital signs he may send the resident directly to the hospital. During an interview on 5/30/20 at 5:15 p.m., NP E said she ordered a KUB on 5/8/20 because it was reported to her that Resident #1 was having pain and abdominal distention. NP E said a KUB could show bladder distension, especially if it was significant. NP E said a KUB could show a urinary obstruction. During an interview on 5/30/20 at 5:30 p.m., the ADON said she could not say for sure the KUB ordered 5/8/20 was ever completed. She said she could not find results for the KUB. She said the X-ray company told her the orders/results for 5/8/20 would be in the old system and were not available. The ADON said the wound care nurse was responsible for following up on orders for which no results have been received. She said the floor nurse should also communicate during shift report with other nurses if they were waiting on results. During an interview on 6/10/20 at 12:00 p.m., the ADON said when a resident was admitted from or returning from the hospital, the discharge summary, history and physical and any orders were sent to the NP. The ADON said pertinent medical information from the hospital discharge summary, orders and/or history and physical should be documented on the 24 hour report. She said pertinent medical history should also be communicated during the oral shift report. She said she was not aware of Resident #1 having abdominal pain or distension until she went to the hospital on [DATE]. The ADON said she was not aware of Resident #1's history of [MEDICAL CONDITION]. The ADON said she was not aware Resident #1 had over 2 L of urine drained from her bladder on 3/28/20. She said there was no order or results for a UA for 5/14/20. The ADON said as far as she knew Resident #1 did not see a urologist. She said the admitting nurse should have communicated Resident #1 had a [DIAGNOSES REDACTED]. During an interview on 5/30/20 at 5:35 p.m., the administrator said it was generally the responsibility of the wound care nurse to follow up on laboratory and other tests ordered for which results had not been received. The administrator said she expected nursing staff to follow up on laboratory and other tests results. She said she expected staff to be aware of and communicate pertinent medical history to other staff members. The website https://www.aafp.org/afp/2008/0301/p643.html accessed on 6/19/20 indicated the following: .[MEDICAL CONDITION] is the inability to voluntarily void urine .acute [MEDICAL CONDITION] is the sudden and often painful inability to void despite having a full bladder .initial management includes bladder catherization and prompt and complete decompression .complications include infection and [MEDICAL CONDITION] . The website https://www.bcm.edu/healthcare/specialties/womens-health-maternity/urogynecology/conditions/urinary-retention accessed 6/19/20 indicated the following: .symptoms of acute bladder retention include severe discomfort, pain in lower abdomen, bloated lower belly .medical professionals may be able to feel your distended bladder by lightly tapping on the lower belly .additional testing includes a urine sample, X-ray or CT .for acute bladder retention, initial treatment will involve catherization, a small tube inserted into the bladder through the urethra to drain the urine and relieve immediate pain and distention .complications of [MEDICAL CONDITION] may include urinary tract infections. When urine stays in the bladder bacteria can grow and infect the urinary tract, bladder damage, [MEDICAL CONDITION] . The administrator and DON were notified 6/10/20 at 4:18 p.m., an immediate jeopardy situation had been identified due to the above failures. The IJ template was provided to the administrator. The Plan of Removal was accepted 6/10/20 at 7:04 p.m. and included the following: 1. Nursing staff will be in-serviced on lab/x-ray process including ordering, reporting and communicating with physician/nurse practitioner with results. Due Date 6/11/20. Team member responsible: ADON. 2. Establish and in-service clinical staff on a diagnostic tracking log. All new orders, including labs & X-rays will be reviewed during morning clinical meeting and cross referenced with diagnostic tracking log to ensure follow-though. Additionally, the diagnostic tracking log will be reviewed during weekly SOC meeting. Due Date 6/11/20. Team member responsible: ADON. 3. Nurses will be in-serviced on importance of passing on resident pertinent medical history on each new admission. Admission / readmission audit tool will be completed and reviewed during morning clinical meeting daily and weekly during SOC meeting. Due Date 6/11/20. Team member responsible: ADON. 4. Compliance of new admission / readmission audit tool and diagnostic tracking log will be reported to QA Committee monthly to ensure ongoing compliance. Due Date 6/11/20 and on-going. Team member responsible: ADON. 5. All current resident records will be reviewed for most recent labs/x-rays to be acted upon and physician notified. Due Date 6/11/20. Team member responsible: ADON. 6. Assess all current residents for bladder distention. Document and notify physician if noted. Due Date 6/11/20. Team member responsible: ADON. On 6/11/20 the investigator confirmed the plan of removal had been implemented sufficiently to remove the immediate threat by: *All resident medical records were reviewed and contained bladder assessments and no resident reported abdominal pain, tenderness or distension. *Six residents indicated a nurse palpated their abdomen and asked them if they were having any pain. *During an interview on 6/11/20 at 11:30 a.m., the regional nurse said an audit was underway of all diagnostic and laboratory orders to ensure they have been completed and reported to the NP or physician. *An order audit document dated 5/11/20-6/11/20 indicated all diagnostic and laboratory orders were audited with no discrepancies noted. *A Daily Diagnostic Tracking Log dated 6/10/20 was reviewed and found to have all recent diagnostic orders logged. For 3 of the 5 residents listed, results had been received, the provider notified, and new orders documented. *The Daily Stand Up Guideline dated 6/11/20 indicated the new admission audit tool and the daily diagnostic tracking log was reviewed and discussed during the daily stand up meeting. *An off-cycle Quality Assurance Committee Meeting sign in sheet dated 6/11/20 indicated a QA meeting was held to address further implementation of corrective actions. *A facility in-service sign in sheet titled Clinical Stand Up dated 6/10/20 indicated the 5 members of clinical management was instructed on the new admission audit tool and the daily diagnostic tracking log and would be reviewed daily in the stand-up meeting. *A facility in-service sign in sheet titled Admission Audit dated 6/10/20 indicated 8 nurses was in-serviced over the new admission audit tool to be completed by the admitting nurse and on-coming nurse. The in-service also indicated the admission tool would be reviewed in the daily stand up meeting with clinical management. *A facility in-service titled Reporting Lab and X-ray reports to NP and MD dated 6/1/20 indicated 15 nurses had been in-serviced to place all orders for labs and x-rays on the 24 hour report sheet to ensure the following shift would follow up. *During an interview on 6/11/20 at 2:00 p.m. the ADON said the facility had started in-servicing regarding placing pending laboratory and x-rays on the 24 hour report sheet prior to the IJ being identified. The ADON said additional in-services over the new admission audit tool and the daily diagnostic tracking log were initiated and all nurses would be in-serviced before returning to work. The ADON said the new admission audit tool was completed on 1 resident since the previous day. *An admission audit tool dated 6/10/20 for a resident contained the medical history of [REDACTED]. *Nine nurses (4 from the 6p-6a shift and 5 from the 6a-6p shift) indicated they received in-service training on the admission audit tool and the daily diagnostic tracking log. They said the admitting nurse must initiate the admission audit tool and the on-coming nurse must complete the admission audit tool if the admitting nurse was unable to complete it on their shift. They said any pertinent medical information obtained from the hospital discharge summary and/or hospital history and physical was to be recorded on the admission audit tool and placed on the 24 hour report sheet to ensure effective communication. The nurses said they were to place any laboratory or diagnostic order on the daily diagnostic tracking log and the 24 hour report. The nurses said they were to do this to ensure the on-coming shift was aware of pending orders and to ensure all diagnostic orders were followed up on during the daily stand up meeting. *During an interview on 6/11/20 at 3:00 p.m., the ADON said nurses would not be allowed to start their shift until they were in-serviced over the new admission audit tool and the daily diagnostic tracking log requirements and documentation. *During an interview on 6/11/20 at 3:10 p.m., the administrator said nurses would not be allowed to start their shift until they were in-serviced over the new admission audit tool and the daily diagnostic tracking log requirements and documentation. The administrator was notified the IJ was lifted on 6/11/20 at 3:50 p.m., however the facility remained out of compliance at a severity level of actual harm and a scope of pattern, due to the facility's need to complete in-service training and evaluate the effectiveness of their plan of removal.

Based on observation, interview, and record review, the facility failed to assess, evaluate, and revise pain relief interventions to ensure adequate pain relief for 2 of 6 residents reviewed for pain. (Resident #s1 and 2) The facility did not implement interventions to ensure pain control for Resident #1 who was admitted to the facility with a Stage 3 pressure injury which deteriorated causing increased severe pain, and resulted in the resident's inability to sit in her wheelchair and prohibited her from fully participating in therapy. Resident #2 admitted to the facility with a healing right [MEDICAL CONDITION]. Resident #2 had pain during care. The facility did not implement interventions to ensure pain control. This failure could place 10 residents receiving pain management at risk for unrelieved pain. Findings included: 1. A face sheet dated 6/28/17 in Resident #1's closed record indicated Resident #1 was [AGE] years old, admitted [DATE], and discharged [DATE]. Physician orders [REDACTED].#1's closed record indicated Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was to receive [MEDICATION NAME] 5 miligram (mg)-325 mg every four hours as needed for pain and routine [MEDICATION NAME] 5mg-325mg three times a day. Resident #1 was also to receive Tylenol 500 mg every four hours as needed for pain. A pain care plan dated 4/26/17 indicated Resident #1 was at risk for pain. The goal indicated Resident #1 would report or demonstrate relief of pain every day over the next 90 days. The interventions included: administer pain medications as and before Resident #1's pain becomes severe, and observe resident for signs of pain with care and interactions. A pain risk assessment dated [DATE] indicated Resident #1 could not verbalize pain, she had a history of [REDACTED]. The May 2017 MAR indicated from 5/9/17 to 5/16/17, Resident #1 received routine [MEDICATION NAME] 50 mg, every 6 hours as ordered. The MAR further indicated from 5/17/17 to 5/30/17, Resident #1 received routine [MEDICATION NAME] 5mg-325mg, three times a day. A Tylenol 500 mg was given as needed (PRN) once each day on 5/17/17, 5/18/17, 5/19/17, 5/22/17, 5/27/17, and 5/29/17 and was given two times on 5/24/17. The most recent MDS dated [DATE] indicated Resident #1 was rarely or never understood, her cognition was severely impaired, and she required total assistance of two staff for transfers, dressing, toileting, and hygiene. Resident #1 did not resist care, had no pain noted on the assessment, and she had a stage 3 pressure ulcer. During an interview on 6/28/17 at 4:33 p.m., the DON said she spoke with Resident #1's physician about Resident #1's pain on 5/23/17. She said Resident #1's daughter was cursing the DON out regarding Resident #1's care and about the resident being sedated. The DON said Resident #1's physician said he was not going to change or increase Resident #1's medication anymore because of the resident's daughter's behavior. The DON said Resident #1 should have been provided with a low air-loss mattress when she was first admitted to the facility. The DON said if the facility did not have a low air loss mattress available, they should have either rented one, or taken one from another resident, if the other resident's wound was less severe than Resident #1's wound. During an interview on 6/28/17 at 4:51 p.m., Resident #1's physician said Resident #1's daughter threatened the DON and complained that Resident #1 was over-sedated. The physician said Resident #1 was experiencing some pain from her sacral wound and her pain was being treated with routine and as needed pain medication. He said he did not make any recommendations to change the resident's pain medication routine at that time, but said he would expect the facility to contact him if Resident #1 was having increased or unresolved pain. He said he was never notified that Resident #1 was having increased or unresolved pain. Nursing notes for Resident #1 included a late entry dated 5/23/17, (completed by the DON on 6/28/17 at 5:10 p.m.,) stating due to Resident #1's family member's statement about the facility attempting to sedate resident with pain medication, Resident #1's physician made no changes to her pain medication at this time. Nursing notes dated 5/24/17 indicated Resident #1 received two doses of Tylenol 500 mg as needed. After the initial dose, Resident #1 was noted with no further signs of pain. After the second dose, Resident #1 was noted to be resting. Physical therapy daily treatment notes dated 5/25/17 indicated Resident #1 visually demonstrated much pain related to her sacral wound. Nursing notes and daily skilled nursing notes dated 5/26/17 indicated Resident #1's pain was managed and controlled, but said movement and positioning made her pain worse, and her pain affected her mobility. Physical therapy daily treatment notes dated 5/26/17 indicated Resident #1 has increased facial discomfort. Resident #1 in bed today to decrease pain on bottom and for pressure relief. Resident #1 grimaced with rolling. Therapy department discussed in morning facility administrative meeting regarding Resident #1's pain associated with her sacral wound. Resident #1 unable to tolerate sitting in wheelchair due to pain, reported to DON. DON reported it would be two more weeks before wound consultant will return. The May 2017 MAR indicated on 5/27/17, Resident #1 received PRN Tylenol 500 mg one time, and the routine [MEDICATION NAME] 5mg-325mg three times a day. Nursing notes and daily skilled nursing notes dated 5/27/17 indicated Resident #1 received Tylenol 500 mg. A follow up note indicated Resident #1 was sleeping. Nursing notes and daily skilled nursing notes dated 5/28/17 indicated Resident #1's pain was being managed and controlled, noting movement and positioning made her pain worse, and her pain affected her mobility. Nursing notes and daily skilled nursing notes dated 5/29/17 indicated Resident #1 received Tylenol 500 mg. There was no follow up note, no evidence that Resident #1's pain was controlled, and no indication the physician was contacted regarding Resident #1's pain. The daily skilled nursing note indicated Resident #1's pain was not being managed and controlled, movement and positioning made her pain worse, and Resident #1's pain was affecting her rehabilitation. During an interview on 6/28/17 at 3:29 p.m., the Physical Therapy Assistant said Resident #1 was in severe pain the last 3-4 days she was at the facility. She said they would check with the nurses and make sure Resident #1 had received her pain medicine prior to bringing her to therapy, but even with the pain medication, Resident #1 continued to be in severe pain. She said Resident #1 was not verbal, but had a lot of facial grimacing. She said at the start of treatment, Resident #1 was able to tolerate therapy well, but it got to the point Resident #1 was unable to sit up for any length of time, and she was no longer able to tolerate a wheelchair. The Physical Therapy Assistant said Resident #1 had to be treated in a geri chair the last 3-4 days because she was in so much pain. During an interview on 6/28/17 at 9:01 a.m., CNA A said Resident #1 was always in pain. She said the nurses would give her medication for pain, but it did not seem to work. She said she turned and repositioned Resident #1 with pillows to keep her as comfortable as possible. CNA A said Resident #1 got up for therapy every day, and when they would put Resident #1 back in bed, she would wince and tightly grip her sheets. During an interview on 6/28/17 at 4:06 p.m. CNA B said Resident #1 had pain every time she turned her in the bed. She said the nurses would always give her something for pain, but it did not seem to help. During an interview on 6/28/17 at 10:22 p.m., RN E said Resident #1 was in quite a bit of pain especially as her wound got worse. She said Resident #1 was on routine and as needed pain medication, and she knew the order had been changed at least once. She said she did not notify the physician of Resident #1s pain each time, because he was already aware of it. She said if the routine pain medication and as needed pain medication had already been given and were not effective, she would try to get Resident #1's mind on something else. She said she would try to get Resident #1 to talk to her, and she would talk to Resident #1. 2. Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE], and had [DIAGNOSES REDACTED]. He had an order for [REDACTED].#3 300 mg-30 mg every 6 hours as needed for pain. Resident #2 did not have any routine pain medication. The most recent MDS dated [DATE] indicated Resident #2s cognition was severely impaired, he did not resist care, and he required extensive assistance of two staff for bed mobility, transfers, dressing, and hygiene. He was totally dependent on staff for toileting. Resident #2 reported frequent pain. A pain care plan updated 6/22/17 indicated Resident #2 was at risk for pain. The goal indicated Resident #2 would report or demonstrate relief of pain every day over the next 90 days. The interventions included: administer pain medications as ordered, give pain medications before pain becomes severe, notify physician of any changes in level or frequency of pain and increase in use of PRN pain medications, and observe resident for signs of pain with care and interactions. A pain risk assessment dated [DATE] indicated Resident #2 can verbalize pain, usual intensity of pain was 0 on a 0-10 scale, and Resident #2 was noted as having a [DIAGNOSES REDACTED]. Nursing notes for Resident #2 indicated on 6/8/17 - Resident #2 admitted to the facility. Resident #2 denied pain when asked. Resident #2 received PRN Tylenol 325 mg at 7:16 p.m. Follow up pain evaluation was a 1. The June 2017 MAR indicated on 06/08/17, Resident #2 received PRN Tylenol 325 mg one time. Nursing notes for Resident #2 indicated on 6/9/17 - Resident #2 had no complaints of right hip pain at 7:54 a.m. Resident #2 received PRN Tylenol 325 mg at 9:08 a.m. Follow up pain evaluation was a 0. The June 2017 MAR indicated on 6/9/17, Resident #2 received PRN Tylenol 325 mg one time Nursing notes indicated on 6/10/17 - Resident #2 with no complaints of pain at 7:55 a.m. Resident #2 received PRN Tylenol 325 mg at 12:52 p.m. Follow up pain this PRN Tylenol 325 mg at 7:16 p.m. Follow up pain evaluation was a 0. Resident #2 was sleeping. The June 2017 MAR indicated on 6/10/17 - Resident #2 received PRN Tylenol 325 mg twice. Nursing notes indicated on 6/11/17, the Physician Assistant was notified of Resident #2's pain status, and a new order was received for routine [MEDICATION NAME] four times a day. Notes indicated Resident #2 received [MEDICATION NAME] with no signs of distress and no more complaints of pain at this time. The notes indicated Resident #2 received PRN Tylenol 325 mg at 9:08 a.m. Follow up pain evaluation indicated the medication was effective. The June 2017 MAR contained the following information regarding Resident #2 's pain and medication provided: Resident #2 received routine [MEDICATION NAME] 50 mg four times a day for 7 days between 6/11/17 and 6/18/17. He was noted as having received those medications as ordered on [DATE], 6/12/17, 6/16/17, 6/17/17, and 6/18/17. The medication was not administered twice on 6/13/17, and the 1:00 p.m. was left blank on 6/15/17. The June 2017 MAR indicated on 6/11/17, Resident #2 received PRN Tylenol 325 mg one time. Nursing notes indicated on 6/12/17 - Resident #2 appeared lethargic, his daughter insisted Resident #2 was in pain. Tylenol was given for pain at 7:34 a.m. Follow up pain evaluation was a 0. The June 2017 MAR indicated on 06/12/17, Resident #2 received PRN Tylenol 325 mg one time. Nursing notes for Resident #2 indicated on 6/13/17 - Resident #2 has a new order (day 2) for [MEDICATION NAME] four times a day for one week and then discontinue. Resident #2 received PRN Tylenol 325 mg at 1:37 p.m. Follow up pain evaluation was a 1. The June 2017 MAR indicated on 06/13/17 Resident #2 received PRN Tylenol 325 mg one time. Nursing notes for Resident #2 on 6/14/17 indicated the following: 6/14/17 - Resident #2 continues to have increased pain. [MEDICATION NAME] is not effective at this time. Family states they do not want Resident #2 to have anything stronger than a Tylenol #3 because it makes the resident loopy. There is no indication of Resident #2 receiving any medication for pain on this date. Nursing notes for Resident #2 indicated on 6/15/17, Resident #2 received PRN Tylenol 325 mg at 12:07 a.m. Follow up pain evaluation indicated Resident #2 was asleep. The June 2017 MAR indicated the same dose of Tylenol. Nursing notes for Resident #2 indicated the following: *6/16/17 - Resident #2 with no complaints of pain at 7:33 a.m. Resident #2 received a new order on this date for Tylenol #3 every 6 hours as needed. Resident #2 received PRN Tylenol 325 mg at 5:21 p.m. Follow up pain evaluation was a 3. The June 2017 MAR indicated one does of Tylenol 325 mg was given one time. Nursing notes for Resident #2 indicated on 6/17/17, Resident #2 did not require the use of Tylenol #3 for pain, and no evidence of pain noted at this time. Nursing notes dated 6/18/17 for Resident #2 indicated the resident was noted to be in a lot of pain. Tylenol-[MEDICATION NAME] #3 300 mg-30mg was administered at 10:55 a.m. The resident's follow up pain evaluation was a 0. The June 2017 MAR indicated on 6/18/17, Resident #2 received PRN Tylenol-[MEDICATION NAME] #3 300 mg-30mg one time. Nursing notes for Resident #2 indicated on 6/20/17, Tylenol-[MEDICATION NAME] #3 300 mg-30mg was administered at 7:59 p.m. Follow up pain evaluation was a 0. The June 2017 MAR indicated on 6/20/17 Resident #2 received PRN Tylenol-[MEDICATION NAME] #3 300 mg-30mg one time. Nursing notes for Resident #2 indicated on 6/24/17, Tylenol-[MEDICATION NAME] #3 300 mg-30mg administered at 12:44 a.m. Follow up pain evaluation was a 0. The June 2017 MAR for 6/24/17 also indicated Resident #2 received the one dose of PRN Tylenol-[MEDICATION NAME] #3, 300-mg - 30 mg. Nursing notes for Resident #2 indicated on 6/25/17 - Tylenol-[MEDICATION NAME] #3 300 mg-30mg administered at 5:30 a.m. Follow up pain evaluation was a 0. Tylenol-[MEDICATION NAME] #3 300 mg-30mg administered at 1:11 p.m. Follow up pain evaluation was a 2. Tylenol-[MEDICATION NAME] #3 300 mg-30mg administered at 7:13 p.m. Follow up pain evaluation was a 1. The June 2017 MAR dated 6/25/17 indicated Resident #2 received PRN Tylenol-[MEDICATION NAME] #3 300 mg-30mg three times. Nursing notes dated 6/26/17 for Resident #2 indicated Tylenol-[MEDICATION NAME] #3 300 mg-30mg administered at 9:21 a.m. Follow up pain evaluation was a 0. The June MAR dated 6/26/17 for Resident #2 also indicated the one dose of Tylenol-[MEDICATION NAME] #3 300 mg-30 mg was given once. Nursing notes for Resident #2 indicated on 6/27/17, Tylenol-[MEDICATION NAME] #3 300 mg-30mg was administered at 9:54 a.m. Resident #2's follow up pain evaluation was a 0. The nursing notes indicated a second dose was given at 6:20 p.m., and the follow up pain evaluation was at a 0. The June 2017 MAR dated 6/27/17 also indicated two doses of Tylenol--[MEDICATION NAME] #3 300 mg-30mg were given. Nursing notes for Resident #2 indicated the following on 6/28/17, Tylenol-[MEDICATION NAME] #3 300 mg-30mg administered at 3:03 p.m. Follow up pain evaluation was a 0. The June 2017 MAR also indicated on 6/28/17 - Resident #2 received PRN Tylenol-[MEDICATION NAME] #3 300 mg-30mg one time. During an observation on 6/28/17 at 8:49 a.m., Resident #2 was sitting in his wheelchair in therapy. Resident #2 was not observed to be in any pain. During an observation and interview on 6/28/17 at 10:43 a.m., Resident #2 was observed sitting in his room. Resident #2 was unable to answer questions appropriately about his care. He denied any pain. During an observation and interview on 6/28/17 at 1:53 p.m., the treatment nurse was in Resident #2's room to treat the pressure injury to his heel. Resident #2 was lying in bed. The treatment nurse asked Resident #2 if he was in any pain prior to doing the treatment, and the resident said he was not. Resident #2 grimaced when the treatment nurse pulled the bandage off. The treatment nurse said she did not check when Resident #2 last received medication, but she thought he received routine pain medication. The treatment nurse then asked Resident #2 if he needed anything for pain, and he said he did not. The treatment nurse said due to Resident #2's dementia, he did not know to ask for pain medication. The treatment nurse proceeded with treatment. The treatment nurse wet a 4x4 gauze with saline and started cleaning the wound bed. While the treatment nurse was cleaning Resident #2's wound, the resident began grimacing and said oh, oh, oh. The treatment nurse continued cleaning the wound. Resident #2 then said it hurts and the treatment nurse stopped the treatment. The treatment nurse said sometimes any movement caused Resident #2 to grimace and hurt and said she would request some pain medicine before finishing the treatment. The treatment nurse checked Resident #2's MAR and said he had not had anything for pain since yesterday evening. She said she should have checked the MAR prior to treatment to see if he had any pain medication prior to his wound care. During an observation and interview on 6/28/17 at 3:40 p.m., Resident #2 was sitting in his wheelchair. The treatment nurse said Resident #2 received his pain medication at 3:03 p.m. The treatment nurse raised Resident #2's right leg to cleanse the wound to his heel. When the treatment nurse raised Resident #2's leg, Resident #2 grimaced saying Oh, oh, oh. The treatment nurse sprayed skin prep spray on the wound and applied a dry dressing. Once the wound care was completed, Resident #2 no longer complained of pain. During an interview on 6/28/17 at 3:29 p.m. The PTA said Resident #2 complained of pain when moving to a standing position, but once he was standing or once he started any activity, he stopped complaining of pain. The PTA said she felt Resident #2's pain was not true, and felt he only said he was in pain because of his dementia. During an interview on 6/28/17 at 10:47 a.m., CNA C said Resident #2 complains of pain every time he is moved in the bed or assisted out of bed. She said she reported Resident #2's pain to the nurse. During an interview on 6/28/17 at 4:06 p.m., CNA B said Resident #2 complained of pain daily. She said Resident #2 holds his right hip and winces every time they move him or help him out of bed. CNA B said Resident #2 only hurts when he is moved. She said she did not report Resident #2's pain to the nurses every time because they were already aware of it. CNA B said each time she told the nurses Resident #2 was in pain, they would say he already got his pain medication. During an interview on 6/28/17 at 4:03 p.m., LVN D said Resident #2 did not usually complain of pain and said the CNAs never reported Resident #2's pain to her. During an interview on 6/28/17 at 4:33 p.m., the DON said they put Resident #2 on routine medication to address his pain. She said the resident had a startle reflex and was not in actual pain. She said the family did not want Resident #2 overmedicated because they wanted him to be alert so he could participate in therapy and go back home. The DON said Resident #2's physician knew about Resident #2's pain. During an interview on 6/28/17 at 4:51 p.m., Resident #2's physician said Resident #2 was supposed to be put on a routine medication for his increased pain. The physician said that was the last time he heard anything about Resident #2 having any pain and he would expect the facility to contact him if the resident's pain medication was not working effectively. A Pain - Clinical Protocol policy revised April 2007 indicated the staff will discuss significant changes in levels of comfort with the Attending Physician who will adjust interventions accordingly. The CMS 670 dated 6/28/17 indicated 10 residents received pain management.

Based on interview and record review, the administrator and DON failed to ensure the facility's resources were managed effectively and efficiently to attain or maintain the highest practicable physical, mental, and psycho-social well-being for 4 of 21 residents reviewed for accidents related to falls. (Resident #s 11, 12, 18 and 20) The administrator and DON failed to ensure staff were monitored, trained, and supervised for prevention of falls and accidents. This fall contributed to Resident #18 being hospitalized and an additional operation on her right knee to repair shredded tendons. The facility did not re-evaluate the effectiveness of interventions and implement new interventions to prevent/reduce Resident #12's falls. Resident #12 fell 10 times from 3/19/16 to 4/13/16. (26 days) Resident #12 sustained a laceration with a hematoma to the left side her head on 3/20/16 and was sent to the emergency room . Resident #12 was sent to the emergency room for evaluation of injuries after falling 3 times on 3/24/16. The facility did not re-evaluate the effectiveness of interventions, modify or replace interventions as needed to prevent/reduce Resident #11's falls. Resident #11 fell 8 times from 1/19/16 to 2/15/16. (28 days) Resident #11 was sent to the emergency room for evaluation of a head injury after falling on 1/19/16, 2/8/16 and 2/15/16 because she hit her head when she fell . RN K did not use a gait belt and Resident #20 fell during a transfer the wheelchair to the toilet. The facility did not implement interventions to prevent further falls. These failures could place 75 residents who were at risk for falls, to have a fall resulting in a serious injury including death, unnecessary pain, and delayed healing. Findings included: During an interview on 4/27/16 at 12:00 p.m., the DON said she was unaware Resident #18 fell in her personal shower. The DON said she had slip resistant strips placed in the common shower rooms, but not in resident rooms that had showers. The DON said she was unaware Resident #18 was transferred without the use of a gait belt. The DON said gait belts were stored in the resident closets for staff to utilize. She said gait belts were also stored at the nurse station. The DON expected gait belts to be used with all transfers. During an interview on 4/27/16 at 12:58 p.m., the administrator said in order for the facility to make sure the nursing needs of the residents were being met they utilized the following tools: the care planning process, ADL management meetings, the morning department head meetings, and the department head rounds to speak with assigned residents. She said he reviewed the incident and accidents, grievances, the quality assurance committee (reviewed falls monthly) to detect trends. The administrator said rounds were made daily to detect problems with resident care. She said staff competencies were performed on each staff member upon hire and annually by the DON and other nursing staff. The administrator did not think Resident #18's fall was a valid injury that required reporting and did not think substandard care was given. 1. A face sheet dated 4/27/16 indicated Resident #18 was [AGE] years old, admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] indicated Resident #18 had problems with balance and required assistance. The nursing admission assessment indicated Resident #18 had decreased range of motion to her knees, required supervision with bed mobility, limited assistance with transfers and toileting, and extensive assistance with ambulation. Problems with balance requiring assistance. An electronically generated care plan dated 4/27/16 indicated on 4/20/16 Resident #18 was a fall risk related to a problem with balance. The goal was .to maintain safety over the next 90 days, by assisting with ADLs as needed, assess medications for contributing factors, keep call light and frequently used personal items within reach, and use of a wheelchair for mobility . The problem of impaired mobility had goals to .maintain or improve physical function in bed mobility, transfer, ambulation, locomotion and range of motion and staff were to assist with transfers over the next 90 days . The intervention was .to provide the appropriate level of assistance to promote safety of the resident . The problem of self-care deficit related to extensive assistance with transfers and ambulation problem indicated the goal was to .maintain or improve self-care areas of dressing, grooming, hygiene, and bathing over the next 90 days . The intervention was to provide assistance with self-care as needed. The care plan did not indicate how many staff was to assist Resident #18. A fall risk assessment dated [DATE] at 7:59 p.m., indicated Resident #18 required assistance with mobility (balance), limited assistance with transfers (lower extremity strength), was full weight bearing and received two or more medications that increased the risk for falls. Resident #18's fall score was a 6 indicative of a low fall risk. A fall risk assessment dated [DATE] at 1:29 p.m., indicated Resident #18required assistance with mobility due to balance, extensive assistance with transfers, partial weight bearing, and received two or more medications that increased the risk for falls. Resident #18's fall risk score was a 10 indicating a high risk to fall. A nursing note dated 4/21/16 at 4:33 a.m., indicated Resident #18 was able to get up to the bathroom independently. A nursing note dated 4/21/16 at 9:37 a.m., indicated Resident #18 had a surgical incision to her right knee with sutures and staples. The incision was covered with a dressing. The right knee was bruised with a puncture wound with scabbing from a previous drain. A nursing note dated 4/21/16 at 1:42 p.m., the ADON documented Resident 18's right leg was not on the foot rest during transport and her foot was caught under the wheelchair. The dressing was removed and the incision had a scant amount of bleeding. The ADON documented the wound was possibly starting to open. During an interview on 4/27/16 at 11:00 a.m., Resident #18 said on 4/21/16 a CNA was assisting her to therapy in the wheelchair when her right foot fell off the foot rest and bent back underneath the chair. During an interview on 4/27/16 at 12:00 p.m., the DON said the charge nurse, ADON and herself failed to complete an incident report concerning Resident #18 's injury sustained on 4/21/16. She said, The failure must have been from miscommunication. An initial occupational therapy assessment dated [DATE] indicated Resident #18 required moderate assistance with bathing, transfers, toileting, and showers. Resident #18 was unable to maintain balance while turning and required moderate assistance to maintain position. The therapy note indicated Resident #18 was at high risk to fall and her balance recovery was severely impaired. Resident #18 required handhold support and moderate assistance to maintain position with balance. A physical therapy treatment note dated 4/21/16 indicated Resident #18 needed moderate assistance with bed mobility, transfers from bed to wheelchair, and wheelchair to rolling walker. An incident report dated 4/23/16 at 10:20 a.m., indicated Resident #18 had a fall in the shower and was bleeding from her right knee. The report indicated Resident #18 had impaired balance and extensive assistance was required with transfers. The report indicated Resident #18 was assisted from the shower and her right knee gave way and the resident fell to the floor. A nursing note dated 4/23/16 10:38 a.m., indicated Resident #18 was being assisted from the shower chair when her right knee gave away and she fell to the floor, on her bottom, and her right knee began bleeding. A nursing note dated 4/23/16 at 10:50 a.m., indicated Resident #18 was transported to the local hospital for evaluation due to fall in the shower with uncontrolled bleeding to right knee. A physician progress notes [REDACTED].#18 fell today injuring her right knee replacement. The emergency room exam indicated the wound ruptured along the surgical incision and a probable knee cap, tendon rupture. Resident #18 was admitted to the hospital for debridement and repair of the right knee. A hospital consultation report dated 4/25/16 indicated Resident #18 was presented to the emergency department on 4/23/16 due to a fall directly on her right knee which resulted in excruciating pain. The note indicated she had a wound dehiscence (rupture along the surgical incision) to right knee and a patellar (knee cap) tendon damage associated with the fall. Resident #18 underwent sharp excisional debridement, lavage, and wound closure with patellar tendon repair. A nurse note dated 4/26/16 at 9:19 p.m., indicated Resident #18 returned to the facility at 5:45 p.m., from the hospital. Resident #18 was in a geriatric chair and was transferred to the bed with assistance of 4 staff. The note indicated Resident #18 had an [DEVICE] to her right leg. A re-admission skin assessment dated [DATE] at 11:28 a.m., indicated an [DEVICE] to Resident #18's right knee. There were three rods above the knee, and three rods below the knee. The knee had large incision with 3 large sutures, 3 small sutures, and 18 staples. The Electronic physician orders [REDACTED].#18 was ordered an ice bag for pain to her right knee, three times daily, on 4/21/16. She had weight bearing as tolerated on 4/20/16, transfer to hospital for evaluation of right knee on 4/23/16, and on 4/27/16 non- weight bearing right knee following readmission. During an interview on 4/27/16 at 11:00 a.m., Resident #18 said on 4/23/16 she fell directly on her right knee while exiting the shower in her personal shower room. She said CNA C was with her during her shower, but did not provide any assistance with bathing or transferring. Resident #18 said CNA C was propped up on the wall beside the shower just watching her. Resident #18 said she returned from the hospital last night, 4/26/16 and could no longer transfer independently, due to the fixator (muscle that acts as a stabilizer of one part of the body during movement of another part). Resident #18 said she felt the second surgical procedure had placed a hardship on her and her family. During an interview on 4/27/16 at 11:35 a.m., RN K said she was the nurse for Resident #18 when she fell on [DATE]. RN K said CNA C reported Resident #18 fell in the shower. She said CNA C said Resident #18's leg gave way and she fell getting out of the shower. RN K said she found Resident #18 sitting on the floor on her buttocks with blood coming from her right knee. RN K said there was not a gait belt on Resident #18, nor did she recall seeing one in the room. RN K said Resident #18 was sent to the local emergency room . During an interview on 4/27/16 at 12:00 p.m., the DON said she spoke to Resident #18 this morning 4/27/16 about her fall and care. She said she was unaware Resident #18 fell in her personal shower. The DON said Resident #18' s shower did not have slip resistant strips in place. The DON said she was unaware Resident #18 was transferred without the use of a gait belt. The DON said gait belts were stored in the resident closets and there are additional gait belts at the nursing stations. The DON said she expected gait belts to be used with all transfers. During an interview on 4/27/16 at 2:25 p.m., Resident #18's responsible party (RP) said she was informed of Resident #18's fall on 4/23/16. The RP said she visited daily and there were not a call light in Resident #18's shower stall or non-skid strips on the floor. During an interview on 4/27/16 at 3:00 p.m., CNA C said on 4/23/16 she walked in Resident #18's room and found her standing up from the toilet. CNA C said she assisted Resident #18 into the shower as requested. CNA C said when Resident #18 started exiting the shower unassisted, she asked the resident to let her apply the gait belt. She said the gait belt was in the bedroom in the wheelchair. CNA C said Resident #18 was stepping out of the shower when she slipped and fell . CNA C said the shower stall did not have a safety bar to hold on to on the right side, and the left side bar was too far away, so Resident #18 reached for the vanity. She said Resident #18 grabbed the vanity with both hands twisting as she exited the shower stall. CNA C said Resident #18 fell and landed on her bottom with her legs out in front of her. She said Resident #18 ' s shower did not have any non -skid strips on the floor. CNA C said the floor was slippery, so she had placed a towel down to help soak up the water. CNA C said she should have had another person assisting with Resident #18's care. CNA C said CNAs had a hand held pocket device with directions for care of the residents. CNA C said she did not have a hand held device, and was not aware of Resident #18's assistance needs. During an observation on 4/27/16 at 3:00 p.m., the shower in Resident #18's room had an entry ledge approximately 3-4 inches high. There were no non-skid strips inside or outside the shower to prevent slips/falls. There was not a call light system in the shower stall. During an interview on 04/27/16 at 4:45 p.m., the DON said the bathroom in Resident #18 should have non-skid strips inside and outside of the shower. She said she had non-skid strips put in the main shower, but did not realize Resident #18's fall occured in her room. 2. A face sheet dated April 2016 indicated Resident #12 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #12 had clear speech had delusions and wandered. She required extensive assistance with ADLs. She was continent of bowel and bladder. The assessment indicated she had no falls prior to entry. A fall risk assessment dated [DATE] indicated Resident #12 was a high risk for falls. A care plan dated 4/23/16 indicated Resident #12 had a potential for falls due to a problem with balance and severely impaired cognitive status. One of the goals was Resident will verbalize understanding of the need for assistance over the next 90 days. Interventions included: anti-roll backs to wheelchair, call sign Call don't Fall put up in room, non-skid strips added to floor, bed/chair alarm (clip alarm), educate resident in safety awareness. The incident/accident reports for Resident #12 included the following: *3/19/16 at 1:43 p.m., staff was alerted by another Resident that Resident #12 was lying on the floor in her room. Actions taken: physical exam, MD notified, family notified, no new interventions implemented (report indicated severely impaired cognitive status, impaired judgment and anxiety). *3/19/16 at 5:17 p.m., Resident #12 was in her wheelchair in the lobby and stood up to use her walker and fell . no new interventions implemented *3/20/16 at 5:30 p.m., nursing staff was notified by dietary staff that Resident #12 had fallen out of her wheelchair and hit her head on the metal door in the dining room. Resident received a ½ inch laceration with hematoma to the left side of her head. sent to emergency room for evaluation, orders received to decrease [MEDICATION NAME] upon return from emergency room *3/24/16 at 1:40 p.m., Resident #12 was sitting at nurses station and attempted to transfer herself from wheelchair to wheelchair and fell . no new interventions implemented *3/24/16 at 6:20 p.m., Resident #12 was sitting at nurses station and attempted to pick something up off floor and fell out of wheelchair striking her head on wall and floor. no new interventions implemented *3/24/16 at 11:30 p.m., Resident #12 was found by staff lying in floor by her bed. no new interventions implemented *3/26/16 at 4:45 p.m., Resident #12 was eating supper in dining room, stood up from wheelchair and fell .no new interventions implemented *3/28/16 at 6:15 p.m., Resident #12 fell when attempting self-transfer from wheelchair to straight chair. no new interventions implemented *4/01/16 at 5:35 p.m., Resident #12 was found sitting on the floor beside her bed. no new interventions implemented *3/13/16 at 5:00 a.m., Resident #12 was found by staff lying on floor in her room. no new interventions implemented During an observation 4/27/16 at 11:10 a.m., Resident #12 was lying on her bed. A bed alarm was clipped to her shirt but the alarm was not secured to the bed. During an observation on 4/27/16 at 11:50 a.m., Resident #12 was in her wheelchair in the dining room. A clip alarm was on the right side of the chair but was not on the resident. During an interview on 4/28/16 at 2:50 p.m., the DON said every morning during their morning meetings all incidents were discussed and care plans and interventions were updated and implemented at that time. 3. A closed record face sheet dated April 2016 indicated Resident #11 was [AGE] years old, admitted [DATE] and discharged to another facility on 2/16/16 with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #11 had clear speech with a BIMS score of 4. She required extensive assistance with ADLs. She was always incontinent of bowel and bladder. The assessment indicated she had falls prior to re-entry with injury. A care plan dated 2/16/16 indicated Resident #11 had a potential for falls due to an unsteady gait and impaired cognitive status. Interventions included: ½ side rails to assist with mobility, anti-roll backs to wheelchair, call sign Call don't Fall put up in her room, remind resident to call when needing assistance, non-skid strips added to floor, pressure alarm on bed, bed in lowest position, falling star symbol on door, resident education to let staff take care of her pads in chair and bed. A fall risk assessment dated [DATE] indicated Resident #11 was a high risk for falls. The incident/accident reports for Resident #11 included the following: *1/19/16 at 1:45 p.m., Resident #11 was found on the floor in her bathroom by a CNA with redness to her forehead. Actions taken: physical exam, sent to emergency room , MD notified, family notified, has non slip strips in room and bathroom, sign to Stop and Call and reoccurring education to resident (report indicates moderately impaired cognitive status and impaired judgment). No new interventions were implemented to prevent falls. *1/24/16 at 11:03 a.m., Resident #11 was sitting in wheelchair beside her bed and fell asleep, slid forward and landed on knees. no new interventions were implemented to prevent falls *1/29/16 at 1:10 p.m., Resident #11 sat in floor in bathroom while brushing her teeth. no new interventions were implemented to prevent falls *2/08/16 at 6:40 a.m., Resident #11 was found on her bottom on the floor by CNA. foot rest were removed from wheel chair *2/08/16 at 6: p.m., Resident #11 was found in the floor when a CNA heard the resident yelling. Resident #11 was found with lower torso in bathroom and upper torso in bedroom. Action taken: physical exam, MD notified, family notified, Resident #11 was sent to emergency room for evaluation due to contusion on back of head. No new interventions were implemented *2/09/16 at 7:30 a.m., Resident #11 was found on the floor in the bathroom. Action taken: MD notified, family notified, labs to be drawn *2/12/16 at 9:20 a.m., Resident #11 was found on the floor in the bathroom after trying to pick-up a toothbrush she dropped.No new interventions were implemented *2/15/16 at 9:45 a.m., Resident #11 fell while in therapy. Therapist said she attempted to walk and fell forward. resident sent to emergency room for evaluation due to hitting her head. Upon return to facility, no new interventions were implemented 4. A physician order [REDACTED].#20 was [AGE] years old, readmitted [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #20 understood others and made herself understood. She required extensive assistance with ADLs. She is a one person assist with transfers. A care plan electronically signed on 3/21/16 indicated Resident #20 was a high risk for falls, and had impaired physical mobility. Goals were the resident would maintain or improve physical function in bed mobility, transfer, ambulation, locomotion, and ROM; locomotion, problem with balance. The resident will be able to move about room and facility as desired. The interventions indicated staff would assist as needed with wheelchair mobility. The resident was legally blind in both eyes and unable to detect shadows. The resident will navigate environment safely, participate in ADLs and enjoy activities of choice to maximum potential; keep most frequently used items in a consistence area within reach, refer to therapy as needed for equipment and assistive devices. She is a one person assist with transfers. During an interview on 4/27/16 at 3:00 p.m., Resident #20 said CNAs never used a gait belt when transferring her. She said she fell in the restroom when being transferred to the toilet. She said the nurse was mad at her for pushing the call light and snatched her on the toilet. During an interview on 4/27/16 at 5:00 p.m., Resident #20's mother said she visited Resident #20 weekly and has never seen a gait belt in her room until that week. She said staff had never used a gait belt to transfer the resident before. During an interview on 4/27/16 at 6:00 p.m., the DON said she was notified by the weekend supervisor on 1/2/16 of Resident #20 ' s had fall. She said there was no incident report filled out and no follow up was done. She said she was responsible for following up on incidents, and the nurse on duty was responsible for filling out the incident report and notifying the family and physician. During an interview on 4/27/16 at 6:15 p.m., RN K said when she was transferring Resident #20 from the wheelchair to the toilet the resident ' s leg started sliding out from under her. She said she lowered Resident #20 to the ground. She said she did not use a gait belt. She said if an incident report was not found then she did not fill one out. No incident report was found. The said she should have filled out and incident report. The only in-service regarding falls was given by the DON on 2/22/16 and was titled Observation Data (Follow up assessment). This in-service was for all nursing staff. The in-service indicated on 3/1/16 nursing staff would begin completing these follow-up fall assessments for I&A (incident/accidents) for 3 days. There was only 4 nurse signatures on the in-service. An Abuse Prohibition Management Program policy and procedure dated February 2010 indicated .all residents in a skilled nursing facility have the right to be free from abuse, corporal punishment, and involuntary seclusion. They have the right to be free from mistreatment, neglect and misappropriation of property. (5)(b) Deployment of staff on each shift in sufficient numbers to meet the need of the residents and assure that the staff assigned have knowledge of the individual residents' care needs . A Patient Safe Handling and Movement policy and procedure dated 10/01/2007 indicated: It is the policy of this facility to care for residents safely while maintaining a safe work environment for employees. To accomplish this, direct care staff should assess residents in advance to determine the safest way to accomplish lifting, transferring, and movement needs. Additionally, mechanical lifting equipment and/or other handling aides should be used to prevent manual lifting and handling of residents except when absolutely necessary. 6. Resident handling aids: Equipment used to assist in the lift or transfer process. Examples: include gait belts with handles, stand assit aids, slide boards, and surface-friction reducing devices .Mechanical lifting devices and other approved handling devises will also be used for high risk residents when appropriate. These devices will be used in accordance with instruction and training. (7) Licensed nurses will insure that mechanical lifting devises and other equipment aids are accessible to direct-care staff. (12) Any incident, accident or injury resulting from resident handling and movement will be report in accordance with facility policy. (14) The QAA committee will identify, assess, and develop strategies to minimize risk of injury to residents and direct-care staff associated with resident lifting, transferring, repositioning, or movement. An undated policy statement regarding accidents and incidents said all accidents or incidents involving residents must be reported to nursing staff. An undated policy statement regarding their fall prevention program indicated when a fall occurred, the staff must document on a Intervention Checklist the date of implementation of interventions. For negative outcome reviews, the interdisciplinary should discuss the fall and assure that the care plan has been updated and that immediate interventions are in place. During an interview on 4/27/16 at 5:50 p.m., Corporate RN K said there were 75 residents at risk for falls.

Based on observation, interview, and record review, the facility failed to implement their wriiten policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for 4 of 21 residents reviewed for neglect. (Residents #s18, 12, 11 and 20) The facility did not provide supervision or assistive devices to prevent Resident #18 from falling while exiting the shower. Resident #18 was admitted on [DATE] for rehabilitation after a right knee replacement. She was a high risk for falls and her balance recovery was severely impaired. Resident #18 fell trying to get out of the shower with CNA C standing by, but not assisting, and sustained an injury requiring hospitalization and surgical intervention. This fall contributed to Resident #18 being hospitalized and an additional operation on her right knee to repair shredded tendons. The facility did not re-evaluate the effectiveness of interventions and implement new interventions to prevent/reduce Resident #12's falls. Resident #12 fell 10 times from 3/19/16 to 4/13/16. (26 days) Resident #12 sustained a laceration with a hematoma to the left side of her head on 3/20/16 and was sent to the emergency room . Resident #12 was sent to the emergency room for evaluation of injuries after falling 3 times on 3/24/16. The facility did not re-evaluate the effectiveness of interventions, modify or replace interventions as needed to prevent/reduce Resident #11's falls. Resident #11 fell 8 times from 1/19/16 to 2/15/16. (28 days) Resident #11 was sent to the emergency room for evaluation of a head injury after falling on 1/19/16, 2/8/16 and 2/15/16. RN K did not use a gait belt and Resident #20 fell during a transfer from the wheelchair to the toilet. The facility did not implement interventions to prevent further falls. These failures could place 75 residents who were identified as fall risks at risk for neglect, serious injury or death. Findings included: An Abuse Prohibition Management Program policy and procedure date February 2010 indicated .all residents in a skilled nursing facility have the right to be free from abuse, corporal punishment, and involuntary seclusion. They have the right to be free from mistreatment, neglect and misappropriation of property. (5)(b) Deployment of staff on each shift in sufficient numbers to meet the need of the residents and assure that the staff assigned have knowledge of the individual residents' care needs . A Patient Safe Handling and Movement policy and procedure dated 10/01/2007 indicated: .It is the policy of this facility to care for residents safely while maintaining a safe work environment for employees. To accomplish this, direct care staff should assess residents in advance to determine the safest way to accomplish lifting, transferring, and movement needs. Additionally, mechanical lifting equipment and/or other handling aides should be used to prevent manual lifting and handling of residents except when absolutely necessary. 6. Resident handling aids: Equipment used to assist in the lift or transfer process. Examples: include gait belts with handles, stand assist aids, slide boards, and surface-friction reducing devices .Mechanical lifting devices and other approved handling devises will also be used for high risk residents when appropriate. These devices will be used in accordance with instruction and training. (7) Licensed nurses will insure that mechanical lifting devises and other equipment aids are accessible to direct-care staff. (12) Any incident, accident or injury resulting from resident handling and movement will be report in accordance with facility policy. (14) The QAA committee will identify, assess, and develop strategies to minimize risk of injury to residents and direct-care staff associated with resident lifting, transferring, repositioning, or movement . An undated fall prevention program policy and procedure indicated .a fall prevention program will be established and maintained, to assess all residents to determine their risks for falls. A plan of care will be implemented based on the resident's assessed needs .(4) (c) Provide resident and family education relative to the resident's particular situation. (Transfer needs, medications side effects, need for assistance . .(4)(c) Assess the environment and make appropriate changes, e.g. bed in low position, personal items within reach, non-stop footwear, night light, walkers, wheelchair within reach, etc . .(4)(f) Offer frequent toileting or follow individualized toileting schedule, if appropriate . .(7) The facility's fall prevention program must comply with State-specific requirements (e.g. regulations, reporting, documentation, etc.) . An undated policy statement regarding accidents and incidents said .all accidents or incidents involving residents must be reported to nursing staff . An undated policy statement regarding their fall prevention program indicated .when a fall occurred, the staff must document on an Intervention Checklist the date of implementation of interventions. For negative outcome reviews, the interdisciplinary should discuss the fall and assure that the care plan has been updated and that immediate interventions are in place . 1. A face sheet dated 4/27/16 indicated Resident #18 was [AGE] years old, admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] indicated Resident #18 had problems with balance and required assistance. The nursing admission assessment indicated Resident #18 had decreased range of motion to her knees, required supervision with bed mobility, limited assistance with transfers and toileting, and extensive assistance with ambulation. Problems with balance requiring assistance. An electronically generated care plan dated 4/27/16 indicated on 4/20/16 Resident #18 was a fall risk related to a problem with balance. The goal was .to maintain safety over the next 90 days, by assisting with ADLs as needed, assess medications for contributing factors, keep call light and frequently used personal items within reach, and use of a wheelchair for mobility . The problem of impaired mobility had goals to .maintain or improve physical function in bed mobility, transfer, ambulation, locomotion and range of motion and staff were to assist with transfers over the next 90 days . The intervention was .to provide the appropriate level of assistance to promote safety of the resident . The problem of self-care deficit related to extensive assistance with transfers and ambulation problem indicated the goal was to .maintain or improve self-care areas of dressing, grooming, hygiene, and bathing over the next 90 days . The intervention was to provide assistance with self-care as needed. The care plan did not indicate how many staff was to assist Resident #18. A fall risk assessment dated [DATE] at 7:59 p.m., indicated Resident #18 required assistance with mobility (balance), limited assistance with transfers (lower extremity strength), was full weight bearing and received two or more medications that increased the risk for falls. Resident #18's fall score was a 6 indicative of a low fall risk. A fall risk assessment dated [DATE] at 1:29 p.m., indicated Resident #18required assistance with mobility due to balance, extensive assistance with transfers, partial weight bearing, and received two or more medications that increased the risk for falls. Resident #18's fall risk score was a 10 indicating a high risk to fall. A nursing note dated 4/21/16 at 4:33 a.m., indicated Resident #18 was able to get up to the bathroom independently. A nursing note dated 4/21/16 at 9:37 a.m., indicated Resident #18 had a surgical incision to her right knee with sutures and staples. The incision was covered with a dressing. The right knee was bruised with a puncture wound with scabbing from a previous drain. A nursing note dated 4/21/16 at 1:42 p.m., the ADON documented Resident 18's right leg was not on the foot rest during transport and her foot was caught under the wheelchair. The dressing was removed and the incision had a scant amount of bleeding. The ADON documented the wound was possibly starting to open. During an interview on 4/27/16 at 11:00 a.m., Resident #18 said on 4/21/16 a CNA was assisting her to therapy in the wheelchair when her right foot fell off the foot rest and bent back underneath the chair. During an interview on 4/27/16 at 12:00 p.m., the DON said the charge nurse, ADON and herself failed to complete an incident report concerning Resident #18 's injury sustained on 4/21/16. She said, The failure must have been from miscommunication. An initial occupational therapy assessment dated [DATE] indicated Resident #18 required moderate assistance with bathing, transfers, toileting, and showers. Resident #18 was unable to maintain balance while turning and required moderate assistance to maintain position. The therapy note indicated Resident #18 was at high risk to fall and her balance recovery was severely impaired. Resident #18 required handhold support and moderate assistance to maintain position with balance. A physical therapy treatment note dated 4/21/16 indicated Resident #18 needed moderate assistance with bed mobility, transfers from bed to wheelchair, and wheelchair to rolling walker. An incident report dated 4/23/16 at 10:20 a.m., indicated Resident #18 had a fall in the shower and was bleeding from her right knee. The report indicated Resident #18 had impaired balance and extensive assistance was required with transfers. The report indicated Resident #18 was assisted from the shower and her right knee gave way and the resident fell to the floor. A nursing note dated 4/23/16 10:38 a.m., indicated Resident #18 was being assisted from the shower chair when her right knee gave away and she fell to the floor, on her bottom, and her right knee began bleeding. A nursing note dated 4/23/16 at 10:50 a.m., indicated Resident #18 was transported to the local hospital for evaluation due to fall in the shower with uncontrolled bleeding to right knee. A physician progress notes [REDACTED].#18 fell today injuring her right knee replacement. The emergency room exam indicated the wound ruptured along the surgical incision and a probable knee cap, tendon rupture. Resident #18 was admitted to the hospital for debridement and repair of the right knee. A hospital consultation report dated 4/25/16 indicated Resident #18 was presented to the emergency department on 4/23/16 due to a fall directly on her right knee which resulted in excruciating pain. The note indicated she had a wound dehiscence (rupture along the surgical incision) to right knee and a patellar (knee cap) tendon damage associated with the fall. Resident #18 underwent sharp excisional debridement, lavage, and wound closure with patellar tendon repair. A nurse note dated 4/26/16 at 9:19 p.m., indicated Resident #18 returned to the facility at 5:45 p.m., from the hospital. Resident #18 was in a geriatric chair and was transferred to the bed with assistance of 4 staff. The note indicated Resident #18 had an [DEVICE] to her right leg. A re-admission skin assessment dated [DATE] at 11:28 a.m., indicated an [DEVICE] to Resident #18's right knee. There were three rods above the knee, and three rods below the knee. The knee had large incision with 3 large sutures, 3 small sutures, and 18 staples. The Electronic physician orders [REDACTED].#18 was ordered an ice bag for pain to her right knee, three times daily, on 4/21/16. She had weight bearing as tolerated on 4/20/16, transfer to hospital for evaluation of right knee on 4/23/16, and on 4/27/16 non- weight bearing right knee following readmission. During an interview on 4/27/16 at 11:00 a.m., Resident #18 said on 4/23/16 she fell directly on her right knee while exiting the shower in her personal shower room. She said CNA C was with her during her shower, but did not provide any assistance with bathing or transferring. Resident #18 said CNA C was propped up on the wall beside the shower just watching her. Resident #18 said she returned from the hospital last night, 4/26/16 and could no longer transfer independently, due to the fixator (muscle that acts as a stabilizer of one part of the body during movement of another part). Resident #18 said she felt the second surgical procedure had placed a hardship on her and her family. During an interview on 4/27/16 at 11:35 a.m., RN K said she was the nurse for Resident #18 when she fell on [DATE]. RN K said CNA C reported Resident #18 fell in the shower. She said CNA C said Resident #18's leg gave way and she fell getting out of the shower. RN K said she found Resident #18 sitting on the floor on her buttocks with blood coming from her right knee. RN K said there was not a gait belt on Resident #18, nor did she recall seeing one in the room. RN K said Resident #18 was sent to the local emergency room . During an interview on 4/27/16 at 12:00 p.m., the DON said she spoke to Resident #18 this morning 4/27/16 about her fall and care. She said she was unaware Resident #18 fell in her personal shower. The DON said Resident #18' s shower did not have slip resistant strips in place. The DON said she was unaware Resident #18 was transferred without the use of a gait belt. The DON said gait belts were stored in the resident closets and there are additional gait belts at the nursing stations. The DON said she expected gait belts to be used with all transfers. During an interview on 4/27/16 at 2:25 p.m., Resident #18's responsible party (RP) said she was informed of Resident #18's fall on 4/23/16. The RP said she visited daily and there were not a call light in Resident #18's shower stall or non-skid strips on the floor. During an interview on 4/27/16 at 3:00 p.m., CNA C said on 4/23/16 she walked in Resident #18's room and found her standing up from the toilet. CNA C said she assisted Resident #18 into the shower as requested. CNA C said when Resident #18 started exiting the shower unassisted, she asked the resident to let her apply the gait belt. She said the gait belt was in the bedroom in the wheelchair. CNA C said Resident #18 was stepping out of the shower when she slipped and fell . CNA C said the shower stall did not have a safety bar to hold on to on the right side, and the left side bar was too far away, so Resident #18 reached for the vanity. She said Resident #18 grabbed the vanity with both hands twisting as she exited the shower stall. CNA C said Resident #18 fell and landed on her bottom with her legs out in front of her. She said Resident #18 ' s shower did not have any non -skid strips on the floor. CNA C said the floor was slippery, so she had placed a towel down to help soak up the water. CNA C said she should have had another person assisting with Resident #18's care. CNA C said CNAs had a hand held pocket device with directions for care of the residents. CNA C said she did not have a hand held device, and was not aware of Resident #18's assistance needs. During an observation on 4/27/16 at 3:00 p.m., the shower in Resident #18's room had an entry ledge approximately 3-4 inches high. There were no non-skid strips inside or outside the shower to prevent slips/falls. There was not a call light system in the shower stall. During an interview on 04/27/16 at 4:45 p.m., the DON said the bathroom in Resident #18 should have non-skid strips inside and outside of the shower. She said she had non-skid strips put in the main shower, but did not realize Resident #18's fall occured in her room. 2. A face sheet dated April 2016 indicated Resident #12 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #12 had clear speech had delusions and wandered. She required extensive assistance with ADLs. She was continent of bowel and bladder. The assessment indicated she had no falls prior to entry. A fall risk assessment dated [DATE] indicated Resident #12 was a high risk for falls. A care plan dated 4/23/16 indicated Resident #12 had a potential for falls due to a problem with balance and severely impaired cognitive status. One of the goals was .Resident will verbalize understanding of the need for assistance over the next 90 days . Interventions included: .anti-roll backs to wheelchair, call sign Call don't Fall put up in room, non-skid strips added to floor, bed/chair alarm (clip alarm), educate resident in safety awareness . The incident/accident reports for Resident #12 indicated she fell with no noted injuries on the following dates: 3/19/16 at 1:43 p.m. and 5:17 p.m. while attempting to stand from her wheelchair; 3/26/16 at 4:45 p.m.; 3/28/16 at 6:15 p.m., 4/1/16 at 5:35 p.m. and 4/13/16 at 6:00 a.m. The incident/accident reports dated 3/19-4/13/16 indicated Resident #12 was moderately impaired cognitive status and impaired judgment. There were no new interventions noted for any of the falls. An incident report dated 3/20/16 at 5:30 p.m., indicated Resident #12 fell out of her wheelchair while leaning forward and hit her head on the metal door in the dining room. Resident #12 received a ½ inch laceration with bruise to the left side of her head. Actions taken: physical exam, physician notified, family notified, sent to emergency room for evaluation. Physician orders [REDACTED]. There were no new interventions noted. The incidents dated 3/24/16 indicated Resident #12 fell at 1:40 p.m., 6:20 p.m. and 11:30 p.m. She was sent to the hospital for evaluation and returned on 3/25/16 with no new orders. There were no new interventions noted for any of the falls. During an observation 4/27/16 at 11:10 a.m., Resident #12 was lying on her bed. A bed alarm was clipped to her shirt, but the alarm was not secured to the bed. There were anti-roll back on the wheelchair, call sign Call don't Fall put up in room and non-skid strips added to floor. During an observation on 4/27/16 at 11:50 a.m., Resident #12 was sitting in her wheelchair in the dining room. A clip alarm was on the right side of the chair, but not on the resident. 3. A closed record face sheet dated April 2016 indicated Resident #11 was [AGE] years old, admitted [DATE] and discharged to another facility on 2/16/16 with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #11 had clear speech with a severe cognitive impairment. She required extensive assistance with ADLs. She was always incontinent of bowel and bladder. The assessment indicated she had falls prior to re-entry with injury. A care plan dated 2/16/16 indicated Resident #11 had a potential for falls due to an unsteady gait and impaired cognitive status. Interventions included: .half side rails to assist with mobility, anti-roll backs to wheelchair, call sign Call don't Fall put up in her room, remind resident to call when needing assistance, non-skid strips added to floor, pressure alarm on bed, bed in lowest position, falling star symbol on door, resident education to let staff take care of her pads in chair and bed . A fall risk assessment dated [DATE] indicated Resident #11 was a high risk for falls. The incident/accident reports for Resident #11 included the following falls without injury: 1/19/16 at 1:45 p.m.; 1/24/16 at 11:03 a.m.; 1/29/16 at 1:10 p.m.; 2/08/16 at 6:40 a.m.; 2/9/16 at 7:30 p.m.; and 2/12/16 at 9:20 a.m. The reports indicated Resident #11 was moderately impaired cognitive status and impaired judgment. There were no new interventions noted for any of the falls. An incident report dated 1/19/16 at 1:45 p.m., indicated Resident #11 was found on the floor in her bathroom by a CNA with redness to her forehead. Actions taken included physical exam, sent to emergency room , physician notified, family notified, has non slip strips in room and bathroom, sign to Stop and Call and reoccurring education to resident (report indicates moderately impaired cognitive status and impaired judgment). No new interventions were implemented to prevent falls. An incident report dated 2/08/16, Resident #11 was found in the floor when a CNA heard the resident yelling. Resident #11 was found with lower torso in bathroom and upper torso in bedroom. Resident #11 was sent to emergency room for evaluation due to contusion on back of head. Resident #11 returned with no new orders. No new interventions were implemented An incident report dated 2/15/16 at 9:45 a.m., indicated Resident #11 fell forward while attempting to walk. Actions taken: physical exam, physician notified, family notified, resident sent to emergency room for evaluation, due to hitting her head. Upon return to facility, no new interventions were implemented. 4. A physician order [REDACTED].#20 was [AGE] years old, readmitted [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #20 understood others and made herself understood. She required extensive assistance with ADLs. She is a one person assist with transfers. A care plan electronically signed on 3/21/16 indicated Resident #20 was a high risk for falls, and had impaired physical mobility. Goals were the resident would maintain or improve physical function in bed mobility, transfer, ambulation, locomotion, and ROM; locomotion, problem with balance. The resident will be able to move about room and facility as desired. The interventions indicated staff would assist as needed with wheelchair mobility. The resident was legally blind in both eyes and unable to detect shadows. The resident will navigate environment safely, participate in ADLs and enjoy activities of choice to maximum potential; keep most frequently used items in a consistence area within reach, refer to therapy as needed for equipment and assistive devices. She is a one person assist with transfers. During an interview on 4/27/16 at 3:00 p.m., Resident #20 said CNAs never used a gait belt when transferring her. She said she fell in the restroom when being transferred to the toilet. She said the nurse was mad at her for pushing the call light and snatched her on the toilet. During an interview on 4/27/16 at 5:00 p.m., Resident #20's mother said she visited Resident #20 weekly and had never seen a gait belt in her room until that week. She said staff had never used a gait belt to transfer the resident before. During an interview on 4/27/16 at 6:15 p.m., RN K said when she was transferring Resident #20 from the wheelchair to the toilet, the resident's leg started sliding out from under her. She said she lowered Resident #20 to the ground. She said she did not use a gait belt. The only in-service regarding falls was given by the DON on 2/22/16 and was titled Observation Data (Follow up assessment). This in-service was for all nursing staff. The in-service indicated on 3/1/16 nursing staff would begin completing these follow-up fall assessments for I&A (incident/accidents) for 3 days. There was only 4 nurse signatures on the in-service. An Abuse Prohibition Management Program policy and procedure dated February 2010 indicated .all residents in a skilled nursing facility have the right to be free from abuse, corporal punishment, and involuntary seclusion. They have the right to be free from mistreatment, neglect and misappropriation of property. (5)(b) Deployment of staff on each shift in sufficient numbers to meet the need of the residents and assure that the staff assigned have knowledge of the individual residents' care needs . A Patient Safe Handling and Movement policy and procedure dated 10/01/2007 indicated: It is the policy of this facility to care for residents safely while maintaining a safe work environment for employees. To accomplish this, direct care staff should assess residents in advance to determine the safest way to accomplish lifting, transferring, and movement needs. Additionally, mechanical lifting equipment and/or other handling aides should be used to prevent manual lifting and handling of residents except when absolutely necessary. 6. Resident handling aids: Equipment used to assist in the lift or transfer process. Examples: include gait belts with handles, stand assit aids, slide boards, and surface-friction reducing devices .Mechanical lifting devices and other approved handling devises will also be used for high risk residents when appropriate. These devices will be used in accordance with instruction and training. (7) Licensed nurses will insure that mechanical lifting devises and other equipment aids are accessible to direct-care staff. (12) Any incident, accident or injury resulting from resident handling and movement will be report in accordance with facility policy. (14) The QAA committee will identify, assess, and develop strategies to minimize risk of injury to residents and direct-care staff associated with resident lifting, transferring, repositioning, or movement. An undated policy statement regarding accidents and incidents said all accidents or incidents involving residents must be reported to nursing staff. An undated policy statement regarding their fall prevention program indicated when a fall occurred, the staff must document on a Intervention Checklist the date of implementation of interventions. For negative outcome reviews, the interdisciplinary should discuss the fall and assure that the care plan has been updated and that immediate interventions are in place. During an interview on 4/27/16 at 5:50 p.m., Corporate RN K said there were 75 residents at risk for falls.

Based on observation, interview, and record review, the facility failed to implement their policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for 4 of 21 residents reviewed for neglect. (Residents #s18, 12, 11, and 20) The facility did not provide supervision or assistive devices to prevent Resident #18 from falling while exiting the shower. Resident #18 was admitted on [DATE] for rehabilitation after a right knee replacement. She was a high risk for falls and her balance recovery was severely impaired. Resident #18 fell trying to get out of the shower with CNA C standing by, but not assisting, and sustained an injury requiring hospitalization and surgical intervention. This fall contributed to Resident #18 being hospitalized and an additional operation on her right knee to repair shredded tendons. The facility did not re-evaluate the effectiveness of interventions and implement new interventions to prevent/reduce Resident #12's falls. Resident #12 fell 10 times from 3/19/16 to 4/13/16. (26 days) Resident #12 sustained a laceration with a hematoma to the left side of her head on 3/20/16 and was sent to the emergency room . Resident #12 was sent to the emergency room for evaluation of injuries after falling 3 times on 3/24/16. The facility did not re-evaluate the effectiveness of interventions, modify or replace interventions as needed to prevent/reduce Resident #11's falls. Resident #11 fell 8 times from 1/19/16 to 2/15/16. (28 days) Resident #11 was sent to the emergency room for evaluation of a head injury after falling on 1/19/16, 2/8/16 and 2/15/16 because she hit her head when she fell . RN K did not use a gait belt and Resident #20 fell during a transfer from the wheelchair to the toilet. The facility did not implement interventions to prevent further falls. These failures could place 75 residents who were identified as fall risks at risk for neglect, serious injury or death. Findings included: 1. A face sheet dated 4/27/16 indicated Resident #18 was [AGE] years old, admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] indicated Resident #18 had problems with balance and required assistance. The nursing admission assessment indicated Resident #18 had decreased range of motion to her knees, required supervision with bed mobility, limited assistance with transfers and toileting, and extensive assistance with ambulation. Problems with balance requiring assistance. An electronically generated care plan dated 4/27/16 indicated on 4/20/16 Resident #18 was a fall risk related to a problem with balance. The goal was .to maintain safety over the next 90 days, by assisting with ADLs as needed, assess medications for contributing factors, keep call light and frequently used personal items within reach, and use of a wheelchair for mobility . The problem of impaired mobility had goals to .maintain or improve physical function in bed mobility, transfer, ambulation, locomotion and range of motion and staff were to assist with transfers over the next 90 days . The intervention was .to provide the appropriate level of assistance to promote safety of the resident . The problem of self-care deficit related to extensive assistance with transfers and ambulation problem indicated the goal was to .maintain or improve self-care areas of dressing, grooming, hygiene, and bathing over the next 90 days . The intervention was to provide assistance with self-care as needed. The care plan did not indicate how many staff was to assist Resident #18. A fall risk assessment dated [DATE] at 7:59 p.m., indicated Resident #18 required assistance with mobility (balance), limited assistance with transfers (lower extremity strength), was full weight bearing and received two or more medications that increased the risk for falls. Resident #18's fall score was a 6 indicative of a low fall risk. A fall risk assessment dated [DATE] at 1:29 p.m., indicated Resident #18 required assistance with mobility due to balance, extensive assistance with transfers, partial weight bearing, and received two or more medications that increased the risk for falls. Resident #18's fall risk score was a 10 indicating a high risk to fall. A nursing note dated 4/21/16 at 4:33 a.m., indicated Resident #18 was able to get up to the bathroom independently. A nursing note dated 4/21/16 at 9:37 a.m., indicated Resident #18 had a surgical incision to her right knee with sutures and staples. The incision was covered with a dressing. The right knee was bruised with a puncture wound with scabbing from a previous drain. A nursing note dated 4/21/16 at 1:42 p.m., the ADON documented Resident 18's right leg was not on the foot rest during transport and her foot was caught under the wheelchair. The dressing was removed and the incision had a scant amount of bleeding. The ADON documented the wound was possibly starting to open. During an interview on 4/27/16 at 11:00 a.m., Resident #18 said on 4/21/16 a CNA was assisting her to therapy in the wheelchair when her right foot fell off the foot rest and bent back underneath the chair. During an interview on 4/27/16 at 12:00 p.m., the DON said the charge nurse, ADON and herself failed to complete an incident report concerning Resident #18 's injury sustained on 4/21/16. She said, The failure must have been from miscommunication. An initial occupational therapy assessment dated [DATE] indicated Resident #18 required moderate assistance with bathing, transfers, toileting, and showers. Resident #18 was unable to maintain balance while turning and required moderate assistance to maintain position. The therapy note indicated Resident #18 was at high risk to fall and her balance recovery was severely impaired. Resident #18 required handhold support and moderate assistance to maintain position with balance. A physical therapy treatment note dated 4/21/16 indicated Resident #18 needed moderate assistance with bed mobility, transfers from bed to wheelchair, and wheelchair to rolling walker. An incident report dated 4/23/16 at 10:20 a.m., indicated Resident #18 had a fall in the shower and was bleeding from her right knee. The report indicated Resident #18 had impaired balance and extensive assistance was required with transfers. The report indicated Resident #18 was assisted from the shower and her right knee gave way and the resident fell to the floor. A nursing note dated 4/23/16 10:38 a.m., indicated Resident #18 was being assisted from the shower chair when her right knee gave away and she fell to the floor, on her bottom, and her right knee began bleeding. A nursing note dated 4/23/16 at 10:50 a.m., indicated Resident #18 was transported to the local hospital for evaluation due to fall in the shower with uncontrolled bleeding to right knee. A physician progress notes [REDACTED].#18 fell today injuring her right knee replacement. The emergency room exam indicated the wound ruptured along the surgical incision and a probable knee cap, tendon rupture. Resident #18 was admitted to the hospital for debridement and repair of the right knee. A hospital consultation report dated 4/25/16 indicated Resident #18 was presented to the emergency department on 4/23/16 due to a fall directly on her right knee which resulted in excruciating pain. The note indicated she had a wound dehiscence (rupture along the surgical incision) to right knee and a patellar (knee cap) tendon damage associated with the fall. Resident #18 underwent sharp excisional debridement, lavage, and wound closure with patellar tendon repair. A nurse note dated 4/26/16 at 9:19 p.m., indicated Resident #18 returned to the facility at 5:45 p.m., from the hospital. Resident #18 was in a geriatric chair and was transferred to the bed with assistance of 4 staff. The note indicated Resident #18 had an [DEVICE] to her right leg. A re-admission skin assessment dated [DATE] at 11:28 a.m., indicated an [DEVICE] to Resident #18's right knee. There were three rods above the knee, and three rods below the knee. The knee had large incision with 3 large sutures, 3 small sutures, and 18 staples. The Electronic physician orders [REDACTED].#18 was ordered an ice bag for pain to her right knee, three times daily, on 4/21/16. She had weight bearing as tolerated on 4/20/16, transfer to hospital for evaluation of right knee on 4/23/16, and on 4/27/16 non- weight bearing right knee following readmission. During an interview on 4/27/16 at 11:00 a.m., Resident #18 said on 4/23/16 she fell directly on her right knee while exiting the shower in her personal shower room. She said CNA C was with her during her shower, but did not provide any assistance with bathing or transferring. Resident #18 said CNA C was propped up on the wall beside the shower just watching her. Resident #18 said she returned from the hospital last night, 4/26/16 and could no longer transfer independently, due to the fixator (muscle that acts as a stabilizer of one part of the body during movement of another part). Resident #18 said she felt the second surgical procedure had placed a hardship on her and her family. During an interview on 4/27/16 at 11:35 a.m., RN K said she was the nurse for Resident #18 when she fell on [DATE]. RN K said CNA C reported Resident #18 fell in the shower. She said CNA C said Resident #18's leg gave way and she fell getting out of the shower. RN K said she found Resident #18 sitting on the floor on her buttocks with blood coming from her right knee. RN K said there was not a gait belt on Resident #18, nor did she recall seeing one in the room. RN K said Resident #18 was sent to the local emergency room . During an interview on 4/27/16 at 12:00 p.m., the DON said she spoke to Resident #18 this morning 4/27/16 about her fall and care. She said she was unaware Resident #18 fell in her personal shower. The DON said Resident #18' s shower did not have slip resistant strips in place. The DON said she was unaware Resident #18 was transferred without the use of a gait belt. The DON said gait belts were stored in the resident closets and there are additional gait belts at the nursing stations. The DON said she expected gait belts to be used with all transfers. During an interview on 4/27/16 at 2:25 p.m., Resident #18's responsible party (RP) said she was informed of Resident #18's fall on 4/23/16. The RP said she visited daily and there were not a call light in Resident #18's shower stall or non-skid strips on the floor. During an interview on 4/27/16 at 3:00 p.m., CNA C said on 4/23/16 she walked in Resident #18's room and found her standing up from the toilet. CNA C said she assisted Resident #18 into the shower as requested. CNA C said when Resident #18 started exiting the shower unassisted, she asked the resident to let her apply the gait belt. She said the gait belt was in the bedroom in the wheelchair. CNA C said Resident #18 was stepping out of the shower when she slipped and fell . CNA C said the shower stall did not have a safety bar to hold on to on the right side, and the left side bar was too far away, so Resident #18 reached for the vanity. She said Resident #18 grabbed the vanity with both hands twisting as she exited the shower stall. CNA C said Resident #18 fell and landed on her bottom with her legs out in front of her. She said Resident #18's shower did not have any non -skid strips on the floor. CNA C said the floor was slippery, so she had placed a towel down to help soak up the water. CNA C said she should have had another person assisting with Resident #18's care. CNA C said CNAs had a hand held pocket device with directions for care of the residents. CNA C said she did not have a hand held device, and was not aware of Resident #18's assistance needs. During an observation on 4/27/16 at 3:00 p.m., the shower in Resident #18's room had an entry ledge approximately 3-4 inches high. There were no non-skid strips inside or outside the shower to prevent slips/falls. There was not a call light system in the shower stall. During an interview on 04/27/16 at 4:45 p.m., the DON said the bathroom in Resident #18 should have non-skid strips inside and outside of the shower. She said she had non-skid strips put in the main shower, but did not realize Resident #18's fall occured in her room. 2. A face sheet dated April 2016 indicated Resident #12 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #12 had clear speech had delusions and wandered. She required extensive assistance with ADLs. She was continent of bowel and bladder. The assessment indicated she had no falls prior to entry. A fall risk assessment dated [DATE] indicated Resident #12 was a high risk for falls. A care plan dated 4/23/16 indicated Resident #12 had a potential for falls due to a problem with balance and severely impaired cognitive status. One of the goals was .Resident will verbalize understanding of the need for assistance over the next 90 days . Interventions included: .anti-roll backs to wheelchair, call sign Call don't Fall put up in room, non-skid strips added to floor, bed/chair alarm (clip alarm), educate resident in safety awareness . The incident/accident reports for Resident #12 indicated she fell with no noted injuries on the following dates: 3/19/16 at 1:43 p.m. and 5:17 p.m. while attempting to stand from her wheelchair; 3/26/16 at 4:45 p.m.; 3/28/16 at 6:15 p.m., 4/1/16 at 5:35 p.m. and 4/13/16 at 6:00 a.m. The incident/accident reports dated 3/19-4/13/16 indicated Resident #12 was moderately impaired cognitive status and impaired judgment. There were no new interventions noted for any of the falls. An incident report dated 3/20/16 at 5:30 p.m., indicated Resident #12 leaned forward and fell out of her wheelchair and hit her head on the metal door in the dining room. Resident #12 received a ½ inch laceration with bruise to the left side of her head. Actions taken: physical exam, physician notified, family notified, sent to emergency room for evaluation. Physician orders [REDACTED]. There were no new interventions noted. The incidents dated 3/24/16 indicated Resident #12 fell at 1:40 p.m., 6:20 p.m. and 11:30 p.m. She was sent to the hospital for evaluation and returned on 3/25/16 with no new orders. There were no new interventions noted for any of the falls. During an observation 4/27/16 at 11:10 a.m., Resident #12 was lying on her bed. A bed alarm was clipped to her shirt, but the alarm was not secured to the bed. There were anti-roll back on the wheelchair, call sign Call don't Fall put up in room and non-skid strips added to floor. During an observation on 4/27/16 at 11:50 a.m., Resident #12 was sitting in her wheelchair in the dining room. A clip alarm was on the right side of the chair, but not on the resident. 3. A closed record face sheet dated April 2016 indicated Resident #11 was [AGE] years old, admitted [DATE] and discharged to another facility on 2/16/16 with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #11 had clear speech with a severe cognitive impairment. She required extensive assistance with ADLs. She was always incontinent of bowel and bladder. The assessment indicated she had falls prior to re-entry with injury. A care plan dated 2/16/16 indicated Resident #11 had a potential for falls due to an unsteady gait and impaired cognitive status. Interventions included: .half side rails to assist with mobility, anti-roll backs to wheelchair, call sign Call don't Fall put up in her room, remind resident to call when needing assistance, non-skid strips added to floor, pressure alarm on bed, bed in lowest position, falling star symbol on door, resident education to let staff take care of her pads in chair and bed . A fall risk assessment dated [DATE] indicated Resident #11 was a high risk for falls. The incident/accident reports for Resident #11 included the following falls without injury: 1/19/16 at 1:45 p.m.; 1/24/16 at 11:03 a.m.; 1/29/16 at 1:10 p.m.; 2/08/16 at 6:40 a.m.; 2/9/16 at 7:30 p.m.; and 2/12/16 at 9:20 a.m. The reports indicated Resident #11 was moderately impaired cognitive status and impaired judgment. There were no new interventions noted for any of the falls. An incident report dated 1/19/16 at 1:45 p.m., indicated Resident #11 was found on the floor in her bathroom by a CNA with redness to her forehead. Actions taken included physical exam, sent to emergency room , physician notified, family notified, has non slip strips in room and bathroom, sign to Stop and Call and reoccurring education to resident (report indicates moderately impaired cognitive status and impaired judgment). No new interventions were implemented to prevent falls. An incident report dated 2/08/16, Resident #11 was found in the floor when a CNA heard the resident yelling. Resident #11 was found with lower torso in bathroom and upper torso in bedroom. Resident #11 was sent to emergency room for evaluation due to contusion on back of head. Resident #11 returned with no new orders. No new interventions were implemented An incident report dated 2/15/16 at 9:45 a.m., indicated Resident #11 fell forward while attempting to walk. Actions taken: physical exam, physician notified, family notified, resident sent to emergency room for evaluation, due to hitting her head. Upon return to facility, no new interventions were implemented. 4. A physician order [REDACTED].#20 was [AGE] years old, readmitted [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #20 understood others and made herself understood. She required extensive assistance with ADLs. She is a one person assist with transfers. A care plan electronically signed on 3/21/16 indicated Resident #20 was a high risk for falls, and had impaired physical mobility. Goals were the resident would maintain or improve physical function in bed mobility, transfer, ambulation, locomotion, and ROM; locomotion, problem with balance. The resident will be able to move about room and facility as desired. The interventions indicated staff would assist as needed with wheelchair mobility. The resident was legally blind in both eyes and unable to detect shadows. The resident will navigate environment safely, participate in ADLs and enjoy activities of choice to maximum potential; keep most frequently used items in a consistence area within reach, refer to therapy as needed for equipment and assistive devices. She is a one person assist with transfers. During an interview on 4/27/16 at 3:00 p.m., Resident #20 said CNAs never used a gait belt when transferring her. She said she fell in the restroom when being transferred to the toilet. She said the nurse was mad at her for pushing the call light and snatched her on the toilet. During an interview on 4/27/16 at 5:00 p.m., Resident #20's mother said she visited Resident #20 weekly and has never seen a gait belt in her room until that week. She said staff had never used a gait belt to transfer the resident before. During an interview on 4/27/16 at 6:00 p.m., the DON said she was notified by the weekend supervisor on 1/2/16 of Resident #20's had fall. She said there was no incident report filled out and no follow up was done. She said she was responsible for following up on incidents, and the nurse on duty was responsible for filling out the incident report and notifying the family and physician. During an interview on 4/27/16 at 6:15 p.m., RN K said when she was transferring Resident #20 from the wheelchair to the toilet the resident's leg started sliding out from under her. She said she lowered Resident #20 to the ground. She said she did not use a gait belt. She said if an incident report was not found then she did not fill one out. No incident report was found. The said she should have filled out and incident report. The only in-service regarding falls was given by the DON on 2/22/16 and was titled Observation Data (Follow up assessment). This in-service was for all nursing staff. The in-service indicated on 3/1/16 nursing staff would begin completing these follow-up fall assessments for I&A (incident/accidents) for 3 days. There was only 4 nurse signatures on the in-service. An Abuse Prohibition Management Program policy and procedure dated February 2010 indicated .all residents in a skilled nursing facility have the right to be free from abuse, corporal punishment, and involuntary seclusion. They have the right to be free from mistreatment, neglect and misappropriation of property. (5)(b) Deployment of staff on each shift in sufficient numbers to meet the need of the residents and assure that the staff assigned have knowledge of the individual residents' care needs . A Patient Safe Handling and Movement policy and procedure dated 10/01/2007 indicated: It is the policy of this facility to care for residents safely while maintaining a safe work environment for employees. To accomplish this, direct care staff should assess residents in advance to determine the safest way to accomplish lifting, transferring, and movement needs. Additionally, mechanical lifting equipment and/or other handling aides should be used to prevent manual lifting and handling of residents except when absolutely necessary. 6. Resident handling aids: Equipment used to assist in the lift or transfer process. Examples: include gait belts with handles, stand assit aids, slide boards, and surface-friction reducing devices .Mechanical lifting devices and other approved handling devises will also be used for high risk residents when appropriate. These devices will be used in accordance with instruction and training. (7) Licensed nurses will insure that mechanical lifting devises and other equipment aids are accessible to direct-care staff. (12) Any incident, accident or injury resulting from resident handling and movement will be report in accordance with facility policy. (14) The QAA committee will identify, assess, and develop strategies to minimize risk of injury to residents and direct-care staff associated with resident lifting, transferring, repositioning, or movement. An undated policy statement regarding accidents and incidents said all accidents or incidents involving residents must be reported to nursing staff. An undated policy statement regarding their fall prevention program indicated when a fall occurred, the staff must document on a Intervention Checklist the date of implementation of interventions. For negative outcome reviews, the interdisciplinary should discuss the fall and assure that the care plan has been updated and that immediate interventions are in place. During an interview on 4/27/16 at 5:50 p.m., Corporate RN K said there were 75 residents at risk for falls.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and adequate supervision and intervention was provided to prevent accidents for 4 of 21 residents reviewed for accidents. (Residents #s 18, 12, 11, and 20) The facility did not provide supervision or assistive devices to prevent Resident #18 from falling while exiting the shower. Resident #18 was admitted on [DATE] for rehabilitation after a right knee replacement. She was a high risk for falls and her balance recovery was severely impaired. Resident #18 fell trying to get out of the shower with CNA C standing by, but not assisting, and sustained an injury requiring hospitalization and surgical intervention. This fall contributed to Resident #18 being hospitalized and an additional operation on her right knee to repair shredded tendons. The facility did not re-evaluate the effectiveness of interventions and implement new interventions to prevent/reduce Resident #12's falls. Resident #12 fell 10 times from 3/19/16 to 4/13/16. (26 days) Resident #12 sustained a laceration with a hematoma to the left side of her head on 3/20/16 and was sent to the emergency room . Resident #12 was sent to the emergency room for evaluation of injuries after falling 3 times on 3/24/16. The facility did not re-evaluate the effectiveness of interventions, modify or replace interventions as needed to prevent/reduce Resident #11's falls. Resident #11 fell 8 times from 1/19/16 to 2/15/16. (28 days) Resident #11 was sent to the emergency room for evaluation of a head injury after falling on 1/19/16, 2/8/16 and 2/15/16 because she hit her head when she fell . RN K did not use a gait belt and Resident #20 fell during a transfer from the wheelchair to the toilet. The facility did not implement interventions to prevent further falls. These failures could place 75 residents who were identified as fall risks at risk for serious injury or death. Findings included: 1. A face sheet dated 4/27/16 indicated Resident #18 was [AGE] years old, admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] indicated Resident #18 had problems with balance and required assistance. The nursing admission assessment indicated Resident #18 had decreased range of motion to her knees, required supervision with bed mobility, limited assistance with transfers and toileting, and extensive assistance with ambulation. Problems with balance requiring assistance. An electronically generated care plan dated 4/27/16 indicated on 4/20/16 Resident #18 was a fall risk related to a problem with balance. The goal was .to maintain safety over the next 90 days, by assisting with ADLs as needed, assess medications for contributing factors, keep call light and frequently used personal items within reach, and use of a wheelchair for mobility . The problem of impaired mobility had goals to .maintain or improve physical function in bed mobility, transfer, ambulation, locomotion and range of motion and staff were to assist with transfers over the next 90 days . The intervention was .to provide the appropriate level of assistance to promote safety of the resident . The problem of self-care deficit related to extensive assistance with transfers and ambulation problem indicated the goal was to .maintain or improve self-care areas of dressing, grooming, hygiene, and bathing over the next 90 days . The intervention was to provide assistance with self-care as needed. The care plan did not indicate how many staff was to assist Resident #18. A fall risk assessment dated [DATE] at 7:59 p.m., indicated Resident #18 required assistance with mobility (balance), limited assistance with transfers (lower extremity strength), was full weight bearing and received two or more medications that increased the risk for falls. Resident #18's fall score was a 6 indicative of a low fall risk. A fall risk assessment dated [DATE] at 1:29 p.m., indicated Resident #18required assistance with mobility due to balance, extensive assistance with transfers, partial weight bearing, and received two or more medications that increased the risk for falls. Resident #18's fall risk score was a 10 indicating a high risk to fall. A nursing note dated 4/21/16 at 4:33 a.m., indicated Resident #18 was able to get up to the bathroom independently. A nursing note dated 4/21/16 at 9:37 a.m., indicated Resident #18 had a surgical incision to her right knee with sutures and staples. The incision was covered with a dressing. The right knee was bruised with a puncture wound with scabbing from a previous drain. A nursing note dated 4/21/16 at 1:42 p.m., the ADON documented Resident 18's right leg was not on the foot rest during transport and her foot was caught under the wheelchair. The dressing was removed and the incision had a scant amount of bleeding. The ADON documented the wound was possibly starting to open. During an interview on 4/27/16 at 11:00 a.m., Resident #18 said on 4/21/16 a CNA was assisting her to therapy in the wheelchair when her right foot fell off the foot rest and bent back underneath the chair. During an interview on 4/27/16 at 12:00 p.m., the DON said the charge nurse, ADON and herself failed to complete an incident report concerning Resident #18 's injury sustained on 4/21/16. She said, The failure must have been from miscommunication. An initial occupational therapy assessment dated [DATE] indicated Resident #18 required moderate assistance with bathing, transfers, toileting, and showers. Resident #18 was unable to maintain balance while turning and required moderate assistance to maintain position. The therapy note indicated Resident #18 was at high risk to fall and her balance recovery was severely impaired. Resident #18 required handhold support and moderate assistance to maintain position with balance. A physical therapy treatment note dated 4/21/16 indicated Resident #18 needed moderate assistance with bed mobility, transfers from bed to wheelchair, and wheelchair to rolling walker. An incident report dated 4/23/16 at 10:20 a.m., indicated Resident #18 had a fall in the shower and was bleeding from her right knee. The report indicated Resident #18 had impaired balance and extensive assistance was required with transfers. The report indicated Resident #18 was assisted from the shower and her right knee gave way and the resident fell to the floor. A nursing note dated 4/23/16 10:38 a.m., indicated Resident #18 was being assisted from the shower chair when her right knee gave away and she fell to the floor, on her bottom, and her right knee began bleeding. A nursing note dated 4/23/16 at 10:50 a.m., indicated Resident #18 was transported to the local hospital for evaluation due to fall in the shower with uncontrolled bleeding to right knee. A physician progress notes [REDACTED].#18 fell today injuring her right knee replacement. The emergency room exam indicated the wound ruptured along the surgical incision and a probable knee cap, tendon rupture. Resident #18 was admitted to the hospital for debridement and repair of the right knee. A hospital consultation report dated 4/25/16 indicated Resident #18 was presented to the emergency department on 4/23/16 due to a fall directly on her right knee which resulted in excruciating pain. The note indicated she had a wound dehiscence (rupture along the surgical incision) to right knee and a patellar (knee cap) tendon damage associated with the fall. Resident #18 underwent sharp excisional debridement, lavage, and wound closure with patellar tendon repair. A nurse note dated 4/26/16 at 9:19 p.m., indicated Resident #18 returned to the facility at 5:45 p.m., from the hospital. Resident #18 was in a geriatric chair and was transferred to the bed with assistance of 4 staff. The note indicated Resident #18 had an [DEVICE] to her right leg. A re-admission skin assessment dated [DATE] at 11:28 a.m., indicated an [DEVICE] to Resident #18's right knee. There were three rods above the knee, and three rods below the knee. The knee had large incision with 3 large sutures, 3 small sutures, and 18 staples. The Electronic physician orders [REDACTED].#18 was ordered an ice bag for pain to her right knee, three times daily, on 4/21/16. She had weight bearing as tolerated on 4/20/16, transfer to hospital for evaluation of right knee on 4/23/16, and on 4/27/16 non- weight bearing right knee following readmission. During an interview on 4/27/16 at 11:00 a.m., Resident #18 said on 4/23/16 she fell directly on her right knee while exiting the shower in her personal shower room. She said CNA C was with her during her shower, but did not provide any assistance with bathing or transferring. Resident #18 said CNA C was propped up on the wall beside the shower just watching her. Resident #18 said she returned from the hospital last night, 4/26/16 and could no longer transfer independently, due to the fixator (muscle that acts as a stabilizer of one part of the body during movement of another part). Resident #18 said she felt the second surgical procedure had placed a hardship on her and her family. During an interview on 4/27/16 at 11:35 a.m., RN K said she was the nurse for Resident #18 when she fell on [DATE]. RN K said CNA C reported Resident #18 fell in the shower. She said CNA C said Resident #18's leg gave way and she fell getting out of the shower. RN K said she found Resident #18 sitting on the floor on her buttocks with blood coming from her right knee. RN K said there was not a gait belt on Resident #18, nor did she recall seeing one in the room. RN K said Resident #18 was sent to the local emergency room . During an interview on 4/27/16 at 12:00 p.m., the DON said she spoke to Resident #18 this morning 4/27/16 about her fall and care. She said she was unaware Resident #18 fell in her personal shower. The DON said Resident #18' s shower did not have slip resistant strips in place. The DON said she was unaware Resident #18 was transferred without the use of a gait belt. The DON said gait belts were stored in the resident closets and there are additional gait belts at the nursing stations. The DON said she expected gait belts to be used with all transfers. During an interview on 4/27/16 at 2:25 p.m., Resident #18's responsible party (RP) said she was informed of Resident #18's fall on 4/23/16. The RP said she visited daily and there were not a call light in Resident #18's shower stall or non-skid strips on the floor. During an interview on 4/27/16 at 3:00 p.m., CNA C said on 4/23/16 she walked in Resident #18's room and found her standing up from the toilet. CNA C said she assisted Resident #18 into the shower as requested. CNA C said when Resident #18 started exiting the shower unassisted, she asked the resident to let her apply the gait belt. She said the gait belt was in the bedroom in the wheelchair. CNA C said Resident #18 was stepping out of the shower when she slipped and fell . CNA C said the shower stall did not have a safety bar to hold on to on the right side, and the left side bar was too far away, so Resident #18 reached for the vanity. She said Resident #18 grabbed the vanity with both hands twisting as she exited the shower stall. CNA C said Resident #18 fell and landed on her bottom with her legs out in front of her. She said Resident #18's shower did not have any non -skid strips on the floor. CNA C said the floor was slippery, so she had placed a towel down to help soak up the water. CNA C said she should have had another person assisting with Resident #18's care. CNA C said CNAs had a hand held pocket device with directions for care of the residents. CNA C said she did not have a hand held device, and was not aware of Resident #18's assistance needs. During an observation on 4/27/16 at 3:00 p.m., the shower in Resident #18's room had an entry ledge approximately 3-4 inches high. There were no non-skid strips inside or outside the shower to prevent slips/falls. There was not a call light system in the shower stall. During an interview on 04/27/16 at 4:45 p.m., the DON said the bathroom in Resident #18 should have non-skid strips inside and outside of the shower. She said she had non-skid strips put in the main shower, but did not realize Resident #18's fall occured in her room. 2. A face sheet dated April 2016 indicated Resident #12 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #12 had clear speech had delusions and wandered. She required extensive assistance with ADLs. She was continent of bowel and bladder. The assessment indicated she had no falls prior to entry. A fall risk assessment dated [DATE] indicated Resident #12 was a high risk for falls. A care plan dated 4/23/16 indicated Resident #12 had a potential for falls due to a problem with balance and severely impaired cognitive status. One of the goals was .Resident will verbalize understanding of the need for assistance over the next 90 days . Interventions included: .anti-roll backs to wheelchair, call sign Call don't Fall put up in room, non-skid strips added to floor, bed/chair alarm (clip alarm), educate resident in safety awareness . The incident/accident reports for Resident #12 indicated she fell with no noted injuries on the following dates: 3/19/16 at 1:43 p.m. and 5:17 p.m. while attempting to stand from her wheelchair; 3/26/16 at 4:45 p.m.; 3/28/16 at 6:15 p.m., 4/1/16 at 5:35 p.m. and 4/13/16 at 6:00 a.m. The incident/accident reports dated 3/19-4/13/16 indicated Resident #12 was moderately impaired cognitive status and impaired judgment. There were no new interventions noted for any of the falls. An incident report dated 3/20/16 at 5:30 p.m., indicated Resident #12 fell out of her wheelchair while leaning forward and hit her head on the metal door in the dining room. Resident #12 received a ½ inch laceration with bruise to the left side of her head. Actions taken: physical exam, physician notified, family notified, sent to emergency room for evaluation. Physician orders [REDACTED]. There were no new interventions noted. The incidents dated 3/24/16 indicated Resident #12 fell at 1:40 p.m., 6:20 p.m. and 11:30 p.m. She was sent to the hospital for evaluation and returned on 3/25/16 with no new orders. There were no new interventions noted for any of the falls. During an observation 4/27/16 at 11:10 a.m., Resident #12 was lying on her bed. A bed alarm was clipped to her shirt, but the alarm was not secured to the bed. There were anti-roll back on the wheelchair, call sign Call don't Fall put up in room and non-skid strips added to floor. During an observation on 4/27/16 at 11:50 a.m., Resident #12 was sitting in her wheelchair in the dining room. A clip alarm was on the right side of the chair, but not on the resident. 3. A closed record face sheet dated April 2016 indicated Resident #11 was [AGE] years old, admitted [DATE] and discharged to another facility on 2/16/16 with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #11 had clear speech with a severe cognitive impairment. She required extensive assistance with ADLs. She was always incontinent of bowel and bladder. The assessment indicated she had falls prior to re-entry with injury. A care plan dated 2/16/16 indicated Resident #11 had a potential for falls due to an unsteady gait and impaired cognitive status. Interventions included: .half side rails to assist with mobility, anti-roll backs to wheelchair, call sign Call don't Fall put up in her room, remind resident to call when needing assistance, non-skid strips added to floor, pressure alarm on bed, bed in lowest position, falling star symbol on door, resident education to let staff take care of her pads in chair and bed . A fall risk assessment dated [DATE] indicated Resident #11 was a high risk for falls. The incident/accident reports for Resident #11 included the following falls without injury: 1/19/16 at 1:45 p.m.; 1/24/16 at 11:03 a.m.; 1/29/16 at 1:10 p.m.; 2/08/16 at 6:40 a.m.; 2/9/16 at 7:30 p.m.; and 2/12/16 at 9:20 a.m. The reports indicated Resident #11 was moderately impaired cognitive status and impaired judgment. There were no new interventions noted for any of the falls. An incident report dated 1/19/16 at 1:45 p.m., indicated Resident #11 was found on the floor in her bathroom by a CNA with redness to her forehead. Actions taken included physical exam, sent to emergency room , physician notified, family notified, has non slip strips in room and bathroom, sign to Stop and Call and reoccurring education to resident (report indicates moderately impaired cognitive status and impaired judgment). No new interventions were implemented to prevent falls. An incident report dated 2/08/16, Resident #11 was found in the floor when a CNA heard the resident yelling. Resident #11 was found with lower torso in bathroom and upper torso in bedroom. Resident #11 was sent to emergency room for evaluation due to contusion on back of head. Resident #11 returned with no new orders. No new interventions were implemented An incident report dated 2/15/16 at 9:45 a.m., indicated Resident #11 fell forward while attempting to walk. Actions taken: physical exam, physician notified, family notified, resident sent to emergency room for evaluation, due to hitting her head. Upon return to facility, no new interventions were implemented. 4. A physician order [REDACTED].#20 was [AGE] years old, readmitted [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #20 understood others and made herself understood. She required extensive assistance with ADLs. She is a one person assist with transfers. A care plan electronically signed on 3/21/16 indicated Resident #20 was a high risk for falls, and had impaired physical mobility. Goals were the resident would maintain or improve physical function in bed mobility, transfer, ambulation, locomotion, and ROM; locomotion, problem with balance. The resident will be able to move about room and facility as desired. The interventions indicated staff would assist as needed with wheelchair mobility. The resident was legally blind in both eyes and unable to detect shadows. The resident will navigate environment safely, participate in ADLs and enjoy activities of choice to maximum potential; keep most frequently used items in a consistence area within reach, refer to therapy as needed for equipment and assistive devices. She is a one person assist with transfers. During an interview on 4/27/16 at 3:00 p.m., Resident #20 said CNAs never used a gait belt when transferring her. She said she fell in the restroom when being transferred to the toilet. She said the nurse was mad at her for pushing the call light and snatched her on the toilet. During an interview on 4/27/16 at 5:00 p.m., Resident #20's mother said she visited Resident #20 weekly and had never seen a gait belt in her room until that week. She said staff had never used a gait belt to transfer the resident before. During an interview on 4/27/16 at 6:15 p.m., RN K said when she was transferring Resident #20 from the wheelchair to the toilet, the resident's leg started sliding out from under her. She said she lowered Resident #20 to the ground. She said she did not use a gait belt. The only in-service regarding falls was given by the DON on 2/22/16 and was titled Observation Data (Follow up assessment). This in-service was for all nursing staff. The in-service indicated on 3/1/16 nursing staff would begin completing these follow-up fall assessments for I&A (incident/accidents) for 3 days. There was only 4 nurse signatures on the in-service. A Patient Safe Handling and Movement policy and procedure dated 10/01/2007 indicated: It is the policy of this facility to care for residents safely while maintaining a safe work environment for employees. To accomplish this, direct care staff should assess residents in advance to determine the safest way to accomplish lifting, transferring, and movement needs. Additionally, mechanical lifting equipment and/or other handling aides should be used to prevent manual lifting and handling of residents except when absolutely necessary. 6. Resident handling aids: Equipment used to assist in the lift or transfer process. Examples: include gait belts with handles, stand assit aids, slide boards, and surface-friction reducing devices .Mechanical lifting devices and other approved handling devises will also be used for high risk residents when appropriate. These devices will be used in accordance with instruction and training. (7) Licensed nurses will insure that mechanical lifting devises and other equipment aids are accessible to direct-care staff. (12) Any incident, accident or injury resulting from resident handling and movement will be report in accordance with facility policy. (14) The QAA committee will identify, assess, and develop strategies to minimize risk of injury to residents and direct-care staff associated with resident lifting, transferring, repositioning, or movement. An undated policy statement regarding accidents and incidents said all accidents or incidents involving residents must be reported to nursing staff. An undated policy statement regarding their fall prevention program indicated when a fall occurred, the staff must document on a Intervention Checklist the date of implementation of interventions. For negative outcome reviews, the interdisciplinary should discuss the fall and assure that the care plan has been updated and that immediate interventions are in place. During an interview on 4/27/16 at 5:50 p.m., Corporate RN K said there were 75 residents at risk for falls.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 4 residents reviewed for pain assessment. (Resident #12) Resident #12 complained of significant episodic pain, daily that compromised his ability to participate in activities of daily living. CNAs H, J, and K continued to transfer Resident #12 even though he cried out in pain. The facility did not evaluate and assess interventions to ensure pain control when Resident #12 reported his medication was not effective. This failure contributed to Resident #12 experiencing significant episodic pain. This failure could place the 47 residents receiving PRN (as needed) pain management at risk for lack of pain assessment, discomfort, and decreased quality of care. Findings included: Physician orders [REDACTED].#12 was [AGE] years old male, admitted on [DATE] with [DIAGNOSES REDACTED]. Medication orders indicated Tylenol arthritis extended release 650 milliggram (mg) every 4 hours as needed for pain. The comprehensive care plan dated 4/8/15 indicated Resident #12 had potential for pain daily with his usual intensity of 8 (0-10 pain scale), his tolerable pain level is 0. Resident #12 had a [DIAGNOSES REDACTED]. The goal was to report relief of pain every day over the next 90 days. The care plan interventions indicated .the nurse would administer pain medications as ordered, give pain medication before pain becomes severe, notify physician of any changes in level or frequency of pain, analyze and document factors that precipitate pain, and what my reduce it, discuss maximum pain relief with physician, assess characteristics of pain: location, severity on a scale of 0-10, type of pain, frequency, precipitating factors, and relief factors, using the pain assessment form. The most recent MDS dated [DATE] indicated Resident #12 could make his-self understood, could understand others, had good recall, required extensive assistance with ADLs. The medication PRN record dated 5/01/15-5/31/15 indicated Resident #12 had not received pain medication from 5/13/15 to 5/20/15. The most recent pain evaluation on 5/20/15 at 10:20 a.m., indicated Resident #12 was 8 on the pain scale of 0-10. The nurse notes dated 5/13/15 to 5/18/15 indicated Resident #12 had no nursing assessments or documentation for 5 consecutive days. There was no physician notification, or attempt to change pain medication since admitted d 4/08/15 and there was no documentation of Resident #12s pain. During an observation and interview on 5/18/15 at 9:32 a.m., Resident #12 was sitting in his wheelchair in the lobby. Resident #12 said he had a lot of pain and it hurt him when CNAs got him out of bed. During an observation and interview on 5/20/15 at 10:05 a.m., CNAs H, J, and K transfered Resident #12 out of bed with a Hoyer lift. Resident #12 cried out in pain when the CNAs moved his left leg. They continued with the transfer. CNAs H, J, and K said Resident #12 yelled out in pain every day, every time they tried to move him. The CNAs said they reported Resident #12's pain to the nurse on duty each time he cried out in pain During an interview on 5/20/15 at 10:05 a.m., Resident #12 said he asked CNA's and nurses for pain medications several times daily, but did not always receive the ordered Tylenol arthritis. Resident #12 said when staff tried to move his left leg his pain was an 8 on the 0-10 pain scale. During an interview on 5/20/15 at 11:00 a.m., LVN L said Resident #12 complained of pain during transfers every time he worked and cared for him. LVN L said he worked 4 to 5 day shifts per week and gave the medications on Resident #12's hall. LVN L said he administered Resident #12 Tylenol arthritis extended release (crushed) at 10:30 a.m., and called the physician with orders for lower extremity x-rays. Resident #12 did not receive pain medication until after surveyor intervention at 10:30 a.m. LVN L said he crushed the Tylenol and had overlooked that it was extended relief and was not to be crushed. LVN L said Resident #12 did not receive the full therapeutic benefit from this pain medication once it was crushed. During an interview on 5/20/15 at 1:55 p.m., Resident #12 said staff did not bring him pain medication when he called for it. He said one of the CNAs told him you just want attention and you are just playing, then continued to lift him out of bed with the Hoyer lift. Resident #12 said he would yell out in pain and they would not stop. He said the staff told him it would be over in a minute. During an interview on 5/20/15 at 2:10 p.m., RN M said Resident #12 refused to take his Tylenol in prior weeks, because it did not help him. RN M said she did not call the physician to report this or attempt to get a stronger pain medication. During an interview on 5/20/15 at 2:37 p.m., CNA O said Resident #12 hollered out in pain anywhere we touched him. CNA O said she and other CNAs tried to hurry as fast as they could to get the transfer over with, because they knew it hurt him. She said she explained to Resident #12 they had to get him up and there was no way around it. She said she reported Resident #12's pain to the nurse on his hall each time he complained. CNA O said she had never heard Resident #12 refuse pain medications. During an interview on 5/20/15 at 2:45 p.m., Resident #12's sister said she talked to the nurses about his pain 3 weeks ago. She said the nurses said they were aware of his pain and would call the doctor to get his pain medication changed. She said she talked to LVN L on 5/19/15 about Resident #12's pain and yelling out, and LVN L told her Resident #12 always did that. During an interview on 5/20/15 at 3:25 p.m., the DON said she expected her staff to rate the resident's pain level using the pain scale (0-10). The nurses should have asked Resident #12 to rate his pain and record his assessment every shift or more often if necessary. The DON said any pain level that was not acceptable to the resident should be medicated with a PRN pain medication. She said nurses were expected to notify the physician if the current pain medication was not effective and this included any residents with pain. The CMS 672 dated 5/18/15 indicated 47 residents had PRN pain medications. Surveyor: Martin, Melanie

Based on interview, and record review, the facility failed to consult with the physician about continued pain for 1 of 4 residents reviewed for pain. (Resident #12) Resident #12 complained of significant episodic pain, daily that compromised his ability to participate in activities of daily living. CNAs H, J, and K continued to transfer Resident #12 even though he cried out in pain. The facility did not evaluate and assess interventions to ensure pain control when Resident #12 reported his medication was not effective. This failure contributed to Resident #12 experiencing significant episodic pain. This failure could place the 47 residents receiving PRN (as needed) pain management at risk for lack of pain assessment, discomfort, and decreased quality of care. Findings included: Physician orders [REDACTED].#12 was [AGE] years old male, admitted on [DATE] with [DIAGNOSES REDACTED]. Medication orders indicated Tylenol arthritis extended release 650 mg every 4 hours as needed for pain. The comprehensive care plan dated 4/8/15 indicated Resident #12 had potential for pain daily with his usual intensity of 8 (0-10 pain scale), his tolerable pain level is 0. Resident #12 had a [DIAGNOSES REDACTED]. The goal was to report relief of pain every day over the next 90 days. The care plan interventions indicated .the nurse would administer pain medications as ordered, give pain medication before pain becomes severe, notify physician of any changes in level or frequency of pain, analyze and document factors that precipitate pain, and what my reduce it, discuss maximum pain relief with physician, assess characteristics of pain: location, severity on a scale of 0-10, type of pain, frequency, precipitating factors, and relief factors, using the pain assessment form . The most recent MDS dated [DATE] indicated Resident #12 could make his-self understood, could understand others, had good recall, required extensive assistance with ADLs. The medication PRN record dated 5/01/15-5/31/15 indicated Resident #12 had not received pain medication from 5/13/15 to 5/20/15. The most recent pain evaluation on 5/20/15 at 10:20 a.m., indicated Resident #12 was 8 on the pain scale of 0-10. The nurse notes dated 5/13/15 to 5/18/15 indicated Resident #12 had no nursing assessments or documentation for 5 consecutive days. There was no physician notification, or attempt to change pain medication since admitted d 4/08/15 and there was no documentation of Resident #12's pain. During an observation and interview on 5/18/15 at 9:32 a.m., Resident #12 was sitting in his wheelchair in the lobby. Resident #12 said he had a lot of pain and it hurt him when CNAs got him out of bed. During an observation and interview on 5/20/15 at 10:05 a.m., CNAs H, J, and K transfered Resident #12 out of bed with a Hoyer lift. Resident #12 cried out in pain when the CNAs moved his left leg. CNAs H, J, and K said Resident #12 yelled out in pain every day, every time they tried to move him. The CNAs said they reported Resident #12's pain to the nurse on duty each time he cried out in pain During an interview on 5/20/15 at 10:05 a.m., Resident #12 said he asked the CNAs and nurses for pain medications several times daily, but did not always receive the ordered Tylenol arthritis. Resident #12 said when staff tried to move his left leg his pain was an 8 on the 0-10 pain scale. During an interview on 5/20/15 at 11:00 a.m., LVN L said R #12 complained of pain during transfers every time he worked and cared for him. LVN L said he worked 4 to 5 day shifts per week and gave the medications on Resident #12s hall. LVN L said he administered Resident #12 Tylenol arthritis extended release (crushed) at 10:30 a.m., and called the physician with orders for lower extremity x-rays. Resident #12 did not receive pain medication until after surveyor intervention at 10:30 a.m. LVN L said he crushed the Tylenol and had overlooked that it was extended relief and was not to be crushed. LVN L said Resident #12 did not receive the full therapeutic benefit from this pain medication once it was crushed. During an interview on 5/20/15 at 1:55 p.m., Resident #12 said staff did not bring him pain medication when he called for it. He said one of the CNAs told him you just want attention and you are just playing, then continued to lift him out of bed with the Hoyer lift. Resident #12 said he would yell out in pain and they would not stop. He said the staff told him it would be over in a minute. During an interview on 5/20/15 at 2:10 p.m., RN M said Resident #12 refused to take his Tylenol in prior weeks, because it did not help him. RN M said she did not call the physician to report this or attempt to get a stronger pain medication. During an interview on 5/20/15 at 2:37 p.m., CNA O said Resident #12 hollered out in pain anywhere we touched him. CNA O said she and other CNAs tried to hurry as fast as they could to get the transfer over with, because they knew it hurt him. She said she explained to Resident #12 they had to get him up and there was no way around it. She said she reported Resident #12's pain to the nurse on his hall each time he complained. CNA O said she had never heard Resident #12 refuse pain medications. During an interview on 5/20/15 at 2:45 p.m., Resident #12's sister said she talked to the nurses about his pain 3 weeks ago. She said the nurses said they were aware of his pain and would call the doctor to get his pain medication changed. She said she talked to LVN L on 5/19/15 about Resident #12's pain and yelling out, and LVN L told her Resident #12 always did that. During an interview on 5/20/15 at 3:25 p.m., the DON said she expected her staff to rate the resident's pain level using the pain scale (0-10). The nurses should have asked Resident #12 to rate his pain and record his assessment every shift or more often if necessary. The DON said any pain level that was not acceptable to the resident should be medicated with a PRN pain medication. She said nurses were expected to notify the physician if the current pain medication was not effective and this included any residents with pain. The CMS 672 dated 5/18/15 indicated 47 residents had PRN pain medications. Surveyor: Martin, Melanie

Based on interview and record review, the administrator and DON failed to ensure: the facility's resources were managed effectively and efficiently to attain or maintain the highest practicable physical, mental, and psycho-social well-being for 2 of 13 residents (Resident #s 1 and 8) reviewed for assessment for change of condition and the environment was as free of accident hazards as possible related to resident use hot water on 4 of 4 halls (Halls 100, 200, 300 and 400) for 4 of 9 residents reviewed for accident hazards. (Residents #s 24, 25, 26, and 27) The administrator and DON failed to ensure staff were monitored, trained, and supervised for documentation of assessments and notifying the physician of residents' changes in condition. Resident #1's leg was swollen. RN Q assessed Resident #1's leg said she felt Resident #1's knee was simply "stiff " from being in an awkward position. RN Q did not document her assessment or notifying the physician of the assessmet. Resident #8's Foley catheter tubing was not secured to prevent pulling and tension. RNs O and G, and LVN P changed Resident #8's indwelling urinary catheter (Foley) catheter on 3/4/14, 4/3/14, 5/3/14, and 6/2/14. Resident #8 sustained significant penile erosion (breakdown of tissue at the catheter insertion site) that resulted in tissue trauma (penile tear) measuring 5 centimeters (cm) long from the urethra down the shaft and 3.5 (cm) wide, of the urethra (tube that connects the bladder to the penis for the removal of fluids from the body) and surrounding penile tissue which was not addressed until 6/2/14, after surveyor intervention. The water temperatures in the lavatory and showers on Halls 100, 200, 300 and 400 ranged from 110.1-121.2 degrees Fahrenheit. (F.) Resident #s 24, 25, 26 and 27 complained the water was too hot. This failure could place the census of 88 residents at risk for failure to receive needed medical intervention and injuries [MEDICAL CONDITION] to hot water. This failure could place 5 residents with Foley catheters at risk for discomfort, urethral trauma and UTIs. Findings included: During an interview on 6/3/14 at 10:02 a.m., the DON said she expected the treatment nurse to document abnormal findings on admission in the nursing notes, and notify the physician and family. The DON said she was unable to locate documentation in Resident #8's clinical record to indicate he had a penile tear on admission or prior to admission. During an interview on 6/4/14 at 11:40 a.m., the DON said no attempts had been made to remove Resident #8's Foley catheter since admission. She said the physician was not notified of the penile tear. During an interview on 6/4/14 at 1:40 p.m., the administrator said the procedures for the resident assessments and changes in condition included the following: *to make sure the resident's nursing needs were being met, she monitored for changes in the resident's condition(s) by looking at the nurse's documentation each morning and attended the daily stand-up meeting where the previous day's falls, injuries, complaints, lab orders, new physician orders [REDACTED]. *to ensure competency she said each nurse had a skills check-off sheet they completed on hire and annually; she did tracking and trending of complaints, incidents, falls, or problem occurrence for the dates, the times, the shifts, a specific nurse or hall, and with this information training, counseling or disciplinary action(s) would occur. *to ensure effectiveness of the facilities processes, the administrator said the department heads met weekly for a standard of cares meeting to discuss, falls, incident and accidents, and other care issues related to resident care. Once a problem was identified, a plan of action was developed to solve and/or investigate further The administrator said Resident #1 was compromised with [MEDICAL CONDITION] and a history of hip replacement. She said the ADL care and straightening of the resident's leg by the CNAs was the reason the leg was fractured. During an interview on 6/4/14 at 1:30 p.m., the DON said the procedures for the resident assessments and changes in condition included the following: *to ensure the nurses were able to care for the residents they were trained in "changes of resident condition " several times in the last six months. Training for "assessments" was done on date of hire and annually and were checked off on a nurse skills check-off sheet. The staff had also had training in transfers and positioning; *there was a change of condition policy and procedure and were expected to follow this and report to ongoing shift of changes in a 24 hour report. The DON said she did not know if Resident #1's leg fracture was spontaneous or due to a change in position. She said Resident # 8's penile tear " had been noticed, but no one thought it worth documenting about. " During an interview on 6/4/14 at 2:00 p.m., the Administrator said the residents' hall water temperatures were checked weekly, and she thought different halls were checked each week. The Administrator said she did not review the monthly water test reports. She reviewed the January- May 2014 water test reports and said all the water temperatures were the same month to month, no variance. She said she had no idea there was any problem with the water temperatures on the halls and had not heard any complaints from residents or staff. A policy and procedure Change in a Resident's Condition or Status dated 4/2007 indicated " ...the nurse should notify the physician when there is an accident or incident, a significant change in condition in status that will not normally resolve itself without intervention without clinical interventions. The nurse would record in the medical record information relative to the changes in the resident's medical/mental condition or status ... " The RN Orientation - Skills Checklist dated 6/20/13 indicated the following related to assessments, documentation and reporting of findings: " ...Admission Process: A. Performs a complete assessment within 24 hours. B. Complete all admission forms 2. Assessment Forms. Change in Conditions: B. Physician Notification Assessments: A. 1) Lesion identification 4) Skin assessment D. [MEDICAL CONDITION] ... " 1. Electronic physician orders [REDACTED].#8, was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#8 had a Foley catheter to gravity and catheter care. The most recent MDS assessment dated [DATE] indicated Resident #8 was understood, understands, required extensive assistance with ADLs and had a catheter. The interim care plan on admitted d 2/4/14 indicated Resident #8 had a Foley catheter, but did not address the penile tear. The comprehensive care plan dated 5/19/14 did not address Resident #8's Foley catheter use, penile tear, or behaviors related to pulling on the catheter tubing. A history and physical dated 2/14/14 by Resident #8's primary physician did not indicate a penile tear. A nurse note dated 2/4/14 did not indicate a penile tear or any abnormal findings to the penis. A skin data sheet dated 5/26/14 under category location of wounds did not indicate a penile injury. During an observation and interview with LVN K on 6/1/14 at 10:18 a.m., Resident #8 was in bed. His catheter tubing was not secured. LVN K said the catheter tubing should be secured. LVN K said Resident #8's penile tear occurred shortly after admission. LVN K said she reported the penile tear to the treatment nurse. She said she did not notify the physician. During an observation and interview with LVN V on 6/1/14 at 3:15 p.m., Resident #8 was lying in his bed. LVN V said there was a skin tear horizontal and vertically down the shaft and base of Resident #8's penis, with a moderate amount of white foul smelling discharge on the penis and scrotum, and yellow-green colored urine in the catheter collection bag. LVN V said she did not know when the penile tear occurred. During an interview on 6/1/14 at 3:20 p.m., RN G said Resident #8 admitted with penile erosion. She said she recalled treating the area with triple antibiotic ointment in the past, but did not document it. RN G said she did not consult the physician on the penile tear. During an interview on 6/2/14 at 2:15 p.m., CNA L said she remembered the tear to Resident #8's penis occurred after admission. CNA L said she reported the tear to the charge nurse. During an interview on 6/2/14 at 4:30 p.m., RN E said Resident #8's Foley catheter had been changed on 3/4/14, 4/3/14, 5/3/14, and 6/2/14. RN E said the penile tear was not documented with the above catheter changes. During an interview on 6/2/14 at 4:38 p.m., RN O said she changed Resident #8's Foley catheter on 4/3/14 and 5/3/14. She said she did not see a penile tear. During an interview on 6/2/14 at 4:43 p.m., LVN P said she changed Resident #8's Foley catheter on 3/4/14 and 6/2/14. She denied seeing a penile tear. During an interview on 6/3/14 at 9:18 a.m., CNA N said she was aware of Resident #8's penile tear. She said she thought she reported it to the charge nurse about one month after his admission. During an observation on 6/3/14 at 1:40 p.m., RN G measured Resident #8's penile tear. She said penile tear was 5 centimeters (cm) long and 3.5 (cm) wide with redness noted at 9 o'clock with a scant amount of bleeding. During an interview on 6/3/14 at 4:35 p.m., NP R said she was "just made aware" of the penile tear after surveyor intervention. She said she examined the area prior to this interview. NP R said this type of tear was from catheter trauma. She said she would have examined the trauma if she had of been notified. NP R said she made new recommendations. NP R said this area of concern should have been documented. A nurse note dated 6/1/14 indicated after notification from the facility Resident #8's physician arrived at the facility to examine the penile tear. A progress note dated 6/1/14 indicated Resident #8's physician indicated a penile tear upon examination. A nurse note, written by RN G, with a computer entry date of 6/2/14 at 9:12 a.m., indicated a late entry for 2/10/14. The note indicated Resident #8 had a torn meatus with skin flaps to head of penis, scar tissue present to urethra, small amount of bloody drainage noted to catheter site and monitoring for further injury. A nurse note dated 6/3/14 indicated Resident #8 had redness at 9 o'clock on the penile tear. The physician orders [REDACTED]. 2. Electronic physician orders [REDACTED].#1 was [AGE] years old, originally admitted on [DATE], and re-admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] did not address Resident #1's cognitive impairment related to her dementia. The MDS indicated she required extensive assistance with transfers, dressing, and personal hygiene. An incident report dated 5/23/14 at 8:40 a.m., indicated the nurse was called to Resident #1's room after the CNA found the resident's upper right leg swollen. There was no evidence of trauma noted. The CNA reported Resident #1 complained of pain while being repositioned. NP R was notified and ordered an X-ray. At 4:39 p.m.,Resident #1's primary care physician was informed Resident #1's broken femur and ordered the resident be sent to the hospital for treatment and evaluation. A provider investigation report dated 5/23/14 indicated Resident #1 complained of pain to leg while being dressed. Resident #1's right leg was noted to be swollen without bruising and her skin was warm, dry and intact. The report indicated on 5/22/14 CNAs U and H noticed Resident #1's right knee was in an awkward position and notified RN Q . RN Q assessed Resident #1's leg and noted it was swollen, without outward signs of trauma. The report indicated RN Q said she felt Resident #1's knee was simply "stiff " from being in an awkward position. RN Q allowed the CNAs to continue providing care. The CNAs lifted Resident #1's leg to straighten out the leg when CNA U reported hearing an audible "pop." CNA H and RN Q denied hearing a "pop." According to the report Resident #1 was resistive to care and complained of pain. The report indicated the investigation was inconclusive as to how Resident #1's knee/leg came to be in the awkward position. The report indicated it was likely Resident #1's leg was broken when the CNAs straightened the leg and the injury exacerbated during the care. Resident #1's fracture occurred just below her previous hip replacement device. The report contained information from Medscape titled Periprosthetic Fractures indicating "... the original placement of an implant may predispose a person to a later fracture and the long term presence of a device may change the structure of a bone and increase the susceptibility to fracture..." Nurses' notes dated May 2014 indicated no documented assessment of Resident #1's leg on May 22, 2014. Nurses' notes dated 5/23/14 indicated RN S assessed Resident #1's leg and noted increased swelling and pain. NP R was notified with new orders received to obtain an upper right leg x-ray. At 4:40 p.m., thephysician was notified of Resident #1's broken femur and ordered the resident to be sent to the hospital for treatment and evaluation. An x-ray report dated 5/23/14 indicated Resident #1 had a moderately displaced oblique fracture extending from the mid distal 3rd of femoral shaft. An x-ray report dated 5/23/14 indicated Resident #1 had a mid shaft spiral fracture. During an interview on 6/2/14 at 11:00 a.m., the DON said CNA U should have asked her coworkers if they heard the "pop" when Resident #1's leg was repositioned. She said Resident #1could move herself in bed and assisted with transfers prior to the incident. The DON said RN Q should have documented her assessment of Resident #1's leg. During an interview on 6/2/14 at 11:15 a.m., CNA B said she worked with Resident #1 on 5/22/14 and 5/23/14. She said she did not notice any abnormalities with Resident #1's legs prior to the end of her shift on 5/22/14. She said she noticed the change in Resident #1's leg the morning of 5/23/14 and immediately reported to the charge nurse. During an interview on 6/2/14 at 2:15 p.m., CNA U said she and CNA H went to Resident #1's room around 9:00 p.m. on 5/22/14 to get the resident ready for bed. She said when they pulled back the sheet they noticed Resident #1's knee was bent and her right heel pointed back towards her buttocks. CNA U said they immediately notified RN Q and did not move the leg until the nurse gave her approval to move the leg. During an interview on 6/2/14 at 3:45 p.m., CNA H said she and CNA U went into Resident #1's room around 9:00 p.m. on 5/22/14 to get the resident ready for bed. When the cover was pulled back they noticed Resident #1's leg was bent with her heel pointing towards her buttocks. CNA H said they immediately notified RN Q and did not move the leg until the nurse assessed the leg and gave her approval to continue with care. During an interview on 6/3/14 at 9:50 a.m., RN Q said she assessed Resident #1's leg on 5/22/14 and did not know why she did not document her assessment in Resident #1 ' s notes on 5/22/14. 3. During an observation on 6/1/14 at 10:12 a.m., the lavatory (sink) water temperature in Resident #9's room (301) was 116.5 degrees F. During observations on 6/2/14 the following water temperatures were noted: *9:55 a.m. - Hall 200 sink in the shower room water temperature was 116.2 F. *10:00 a.m. - Hall 100 shower water temperature was 117.4 F. *10:05 a.m. - room [ROOM NUMBER] lavatory temperature was 110.1 F. *10:15 a.m. - room [ROOM NUMBER] lavatory temperature was 110.3 F. During an interview on 6/2/14 at 10:50 a.m., the maintenance supervisor said he tried to keep the residents' lavatory and shower water temperatures between 106 and 108 F. He said the temperatures would be within the appropriate range one day and would be above range the next. He said water temperatures were hard to control. During observation on 6/3/14 the following water temperatures were noted: *10:40 a.m. - room [ROOM NUMBER] lavatory water temperature was 112.5 F. *10:50 a.m. - room [ROOM NUMBER] lavatory water temperature was 111.4 F. *10:53 a.m. - room [ROOM NUMBER] lavatory water temperature was 121.2 F. A Quarterly MDS dated [DATE] indicated Resident # 26 could make herself understood and could understand others. During an interview on 6/3/14 at 1:30 p.m., Resident #26 said the shower water on her hall was too hot. Resident #26 said she asked the CNA assisting her with the shower to cool it off. Resident #26 said they needed to get the water temperature down. A Quarterly MDS dated [DATE] indcated Resident #27 could make herself understood and could understand other. During an interview on 6/3/14 at 1:30 p.m., Resident #27 said the shower water was too hot. She said they had a hard time regulating it during showers to get the right temperature. A Quarterly MDS dated [DATE] indicated Resident #24 could make herself understood and could understand others. During an interview on 6/3/14 at 1:43 p.m., Resident #24 said the shower water was too hot. She said at times she was afraid she would get scalded. She said the last time it was too hot was on Saturday 5/31/14. She said she told the maintenance supervisor about it, and he told her he had trouble regulating the water all over the building and he would fix it. A Quarterly MDS dated [DATE] indicated Resident #25 could make herself understood and could understand others. During an interview on 6/3/14 at 1:50 p.m., Resident #25 said the shower water was too hot. She said she knew you could get scalded, so she tried to "watch it." During an interview on 6/3/14 at 2:45 p.m., the maintenance supervisor said he checked water temperatures every day at the hot water heater and checked water temperatures in rooms on Fridays. He said he thought the temperature could be 105-115 degrees F. He said the mixing valves fluctuated and he did not know they would exceed 110 degrees F. During an interview on 6/1/14 at 10:15 a.m., CNAs C and JJ said the water in the shower rooms did get hot and they were careful to adjust it when it was too hot for the residents The maintenance logged water temperatures test reports from January- May 2014 indicated the water temperatures in the lavatories and showers to be from 106 F to 107 F. An undated hot water temperature policy said " ...resident use hot water would be reliably controlled, such as by thermostatic or mixing valves to not exceed 110 degrees Fahrenheit ... " The CMS 672 date 6/1/14 indicated the census was 88. Five (5) residents had Foley catheters.

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 15 residents reviewed for medications. (Resident #12 ) Resident # 12 received routine [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg-325mg 5 times daily (pain), [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg-325mg as needed every 4 hours , [MEDICATION NAME] ([MEDICATION NAME]- muscle relaxant) 5 mg as needed, and [MEDICATION NAME] 0.5 mg one tablet by mouth every 6 hours as needed (anxiety). No reduction had been attempted, and she had fallen 3 times in the last 2 months. This failure could place the 22 residents receiving pain medications at risk for over sedation at risk for falls and decreased quality of life. Findings included: Electronic physician orders [REDACTED].#12 was [AGE] years old and admitted on 3/ 27/11 with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. *[MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg one by mouth at 5 p.m., *[MEDICATION NAME]-[MEDICATION NAME] 7.5 mg-325mg 1 tablet by mouth 5 times per day every 4 hours while awake. (Doses are 7a.m, 11a.m., 3:00 p.m., 7 pm., and 11 p.m.) -pain *[MEDICATION NAME] 100 mg one by mouth two times a day. (Pain) *[MEDICATION NAME] ([MEDICATION NAME]- muscle relaxant) 5 mg one by mouth every 8 hours as needed for muscle spasms. *[MEDICATION NAME]-[MEDICATION NAME] 7.5 mg-325mg 1 tablet by mouth every 4 hours as needed. *[MEDICATION NAME] 0.5 mg one tablet by mouth every 6 hours as needed. A hospital physician order [REDACTED].#12's fall precautions were "...monitor neuros every 4 hours for head injury, sling and follow-up with primary physician 2-3 days..." The most recent MDS assessment dated [DATE] indicated Resident #12 usually made herself understood and usually understood others. She required extensive total care for all of her ADLs. Resident #12 had limitation on one side to her upper and lower extremity. The MDS indicated she had no falls. A nursing care plan updated 3/28/14 indicated Resident #12 had a potential for falls related to impaired balance, generalized weakness and history of falls. The care plan indicated she fell on [DATE], 5/5/14, and 5/30/14. Interventions included "... call light in reach, bed alarm, assist with transfers times 2, monitor medications for potential side effects, refer to therapy to evaluate and treat, notify MD of any changes in condition, fall assessment updated, and staff to monitor that resident was in lowest position." An undated note indicated she had been referred to therapy. A fall screen dated 5/30/14, indicated Resident #12 scored a "9". (A score between 7-18 = high risk for falls). Incident/Accident reports for Resident #12 included the following: * 3/28/14 at 7:00 p.m.- fell sitting on side of bed, leaned on tray table and fell to floor... Injury- hematoma on forehead/head injury, alert and oriented times 3, sent to ER (emergency room ) and returned. * 5/5/14 at 5:30 a.m.- fell from bed (fell asleep sitting on edge of bed and fell forward)- hematoma, laceration, pain upon movement,-head injury. Alert and oriented times 3, impaired sitting balance, total dependent on transfer, full weight bearing. Sent to ER, call light in reach, bed in low position, redirected, physical therapy to evaluate, restorative program, therapy recommended to have bed side table locked at bed side at all times within reach and refrain from leaning on table when tired. * 5/30/14 4:00 a.m.- fell from bed, lying on right side, says fell asleep sitting on edge of bed. Sent to the ER, unclutterred room, call light in reach, easy access to desired items, and bed in low position, chair alarm and redirected. Resident #12's nursing notes at the time of the fall indicated the following: * 3/28/14 at 3:18 a.m., she received [MEDICATION NAME] 5 mg-1 tablet and a PRN [MEDICATION NAME]- [MEDICATION NAME] 7.5 mg -325 mg 1 tablet. (She received her daily [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg -325 mg times 5 routine.) - 7:30 p.m., found on floor, hit forehead, left pupil pinpoint non-reactive, transported to the hospital. * 5/5/14 at 3:30 a.m., complained of generalized pain, siting on side of bed, alarm unclipped ,refused to clip alarm. [MEDICATION NAME] 7.5 mg/325 mg given for pain. -5:30 a.m.- lying on floor next to bed, bleeding from head, hematoma to right side of head, complained of right shoulder and hip pain. Sent to ER. * 5/30/14 3:56 a.m., [MEDICATION NAME]- [MEDICATION NAME] 7.5 mg -325 mg -1 tablet by mouth for pain. (no notes describing discomfort.) - 4:00 a.m.,- heard alarm , resident lying on the floor on her right side, complained of her right arm hurting, denied hitting head, bruise to her right elbow, continued with ecchymosis (bruising) to her right head and hip from last fall. During an observation on 6/2/14 at 4:10 p.m., Resident #12 was sitting on her side of the bed visiting with friends. During an observation on 6/3/14 at 12:10 p.m., Resident #12 was sitting on the side of her bed, eating lunch, alert with purple bruising noted beneath her right eye. During an observation 6/4/14 at 1:00 p.m., Resident #12 was sitting on the side of her bed, and the bed alarm was unclipped. She said she didn't feel well and rubbed her right chest and said, "You know I broke that bone." During an interview on 6/3/14 at 3:35 p.m., Resident #12 said she had fallen a few times recently. She denied having her medications changed and said usually her pain scale was "0". She said she had not received therapy in several months, never had a pad on the floor, or a recliner in her room, her mattress had remained the same. She now tried to lie down when she became sleepy. During an observation 6/4/14 at 1:00 p.m., Resident #12 was sitting on the side of her bed, and the bed alarm was unclipped. She said she didn't feel well and rubbed her right chest and said, "You know I broke that bone." During an interview on 6/4/14 at 9:25 a.m., LVN A said no one had looked at Resident #12's medications as a possible relation to her falls. LVN A said Resident #12 knew her last pain medication was received at 11 p.m. and usually wanted addtitional medication before her next dose at 7:00 a.m... LVN A said when they added additional PRN pain medication; it had been discussed that alternatives should be tried before giving her additional pain medication, she did not think that was always done. LVN A said she had been concerned with her increased medication. During an interview on 6/4/14 at 10:35 a.m., the consultant pharmacist said he had made recommendations the beginning of May 2014 regarding Resident #12's pain medications, anti-anxiety, muscle relaxant medications and how these medications could result in falls. He said he had given his recommendations to the ADON. The pharmacy consultant report dated May 1- May7, 2014 indicated Resident #12 received [MEDICATION NAME] chloride ([MEDICATION NAME]/[MEDICATION NAME]), [MEDICATION NAME] HCL (Urispas/reduces spasms), [MEDICATION NAME] (anti-anxiety), [MEDICATION NAME] HCL ([MEDICATION NAME]/muscle relaxant). His note said frequent PRN use noted with [MEDICATION NAME] and recently [MEDICATION NAME]. He discussed the [MEDICATION NAME] effects, and potential CNS (central nervous system) effects. His note went on to say how [MEDICATION NAME] had high sedating properties and increased risk of fracture and questionable efficacy when used in the elderly. He mentioned her increased use of her PRN [MEDICATION NAME] and [MEDICATION NAME]/APAP, and the combination of medications could be related to her falls and physical complaints. The pharmacist said the medications with her [MEDICATION NAME] usage could put her at high risk of significant bleeding due to falls. The ADON's written comments regarding pharmacy recommendations dated 5/12/14 included: monitoring her lab work (INRs-international normalization ratio- for [MEDICATION NAME]), monitoring her PRN [MEDICATION NAME] closely and monitoring her [MEDICATION NAME] per nursing assessments. During an interview on 6/4/14 at 10:55 a.m., the ADON said Resident #12 did not want to change her medications. She reviewed her medications after her falls but did not change anything. The ADON said nursing had been offering her non-pharmacologic alternatives prior to medicating Resident #12. The ADON could not provide documentation on her care plan, nursing notes, assessments or other nursing records that Resident #12's medications had been reviewed; alternatives to medications had been tried or medication reductions had been attempted. An undated fall prevention and management program policy said a fall prevention program would be established and maintained to assess all residents to determine their risks for falls. A plan of care would be implemented based on the resident's assessed needs.... An intervention said to monitor and reduce medications when appropriate. The United States National Library of Medicine National Institutes of Health, pub med, www.ncbi.nlm.nih.gov/pubmed/ 204 y accessed on 6/11/14 indicated "...However, elderly patients who are deemed to be at risk of falls are often not started on [MEDICATION NAME] therapy secondary to a perceived higher risk of bleeding complications..." The American Geriatric Society at www.americangeriatrics.org/files/.../beers/2012BeersCriteria_JAGS accessed on 6/11/14 indicated: "...Skeletal muscle relaxants: Most muscle relaxants are poorly tolerated by older adults because of [MEDICATION NAME] adverse effects, sedation, risk of fracture; effectiveness at dosages tolerated by older adults is questionable.... (this included [MEDICATION NAME]) The ADON on 6/4/14 at 3:30 p.m., provided a list indicating 22 residents received routine pain medications.

Based on observation, interview, and record review, the facility failed to ensure: supervision was provided to prevent accidents for 2 of 19 residents reviewed for falls. (Resident #s 12 and 19) and failed to ensure the environment was as free of accident hazards as possible related to resident use hot water on 4 of 4 halls (Halls 100, 200, 300 and 400) for 4 of 9 residents reviewed for accident hazards. (Residents #s 24, 25, 26, and 27) Resident #12 fell on [DATE], 5/5/14 and 5/30/14 and sustained head injuries, a broken right clavicle and bruising. She received as needed (PRN) medications including one or more of pain/muscle relaxer/ anti-anxiety medications during all 3 falls. Resident #12's medications were not reviewed as a possible cause of her falls. Resident #19 was left unsupervised and fell from her wheelchair. Halls 100, 200, 300 and 400 had water temperatures in both the lavatory and shower rooms that ranged from 110.1-121.2 degrees Fahrenheit. (F.) Resident #s 24, 25, 26 and 27 complained the water was too hot. These failures could place the 81 residents at risk of injuries related to falls and 88 residents at risk for burns related to hot water. Findings included: Electronic physician orders [REDACTED].#12 was [AGE] years old and admitted on 3/ 27/11 with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. * Coumadin 2.5 milligram (mg) one by mouth at 5 p.m., *hydrocodone-acetaminophen (pain)7.5 mg-325mg 1 tablet by mouth 5 times per day every 4 hours while awake. (Doses are 7a.m, 11a.m., 3:00 p.m., 7 pm., and 11 p.m.) *Gabapentin (pain) 100 mg one by mouth two times a day. *cyclobenzaprine (Flexeril- muscle relaxant) 5 mg one by mouth every 8 hours as needed for muscle spasms. *hydrocodone-acetaminophen (pain) 7.5 mg-325mg 1 tablet by mouth every 4 hours as needed. *lorazepam (anxiety) 0.5 mg one tablet by mouth every 6 hours as needed. A hospital physician order [REDACTED].#12's fall precautions included monitor neurological assessment every 4 hours for head injury, sling and follow-up with primary physician 2-3 days. The most recent MDS assessment dated [DATE] indicated Resident #12 usually made herself understood and usually understood others. She required extensive total care for all of her ADLs. Resident #12 had limitation on one side to her upper and lower extremity. The MDS indicated she had no falls. A nursing care plan updated 3/28/14 indicated Resident #12 had a potential for falls related to impaired balance, generalized weakness and history of falls. The care plan indicated she fell on [DATE], 5/5/14, and 5/30/14. Interventions included "... call light in reach, bed alarm, assist with transfers times 2, monitor medications for potential side effects, refer to therapy to evaluate and treat, notify MD of any changes in condition, fall assessment updated, and staff to monitor that resident was in lowest position..." An undated note indicated she had been referred to therapy. A fall screen dated 5/30/14, indicated Resident #12 scored a "9" and at high risk for falls. (A score between 7-18 = high risk for falls). Incident/Accident reports for Resident #12 included the following: * 3/28/14 at 7:00 p.m. - fell sitting on side of bed, leaned on tray table and fell to floor... Injury- hematoma on forehead/head injury, alert and oriented times 3, sent to ER (emergency room ) and returned. * 5/5/14 at 5:30 a.m. - fell from bed (fell asleep sitting on edge of bed and fell forward)- hematoma, laceration, pain upon movement,-head injury. Alert and oriented times 3, impaired sitting balance, total dependent on transfer, full weight bearing. Sent to hospital, call light in reach, bed in low position, redirected, physical therapy to evaluate, restorative program, therapy recommended to have bed side table locked at bed side at all times within reach and refrain from leaning on table when tired. *5/30/14 at 4:00 a.m.- fell from bed, lying on right side, says fell asleep sitting on edge of bed. Sent to the hospital, unclutterred room, call light in reach, easy access to desired items, and bed in low position, chair alarm and redirected. Resident #12's nursing notes at the time of the fall indicated the following: *3/28/14 at 3:18 a.m., she received cyclobenzaprine 5 mg-1 tablet and a PRN hydrocodone- acetaminophen 7.5 mg -325 mg 1 tablet. Resident #12's MAR indicated she received her daily hydrocodone-acetaminophen 7.5 mg -325 mg at 7:00 a.m., 11:00 a.m., 3:00 p.m., 7:00 p.m. and 11:00 p.m. She received 5 routine doses. at 7:30 p.m., found on floor, hit forehead, left pupil pinpoint non-reactive, transported to the hospital. *5/5/14 at 3:30 a.m., complained of generalized pain, siting on side of bed, alarm unclipped, refused to clip alarm. Hydrocodone 7.5 mg/325 mg given for pain. -5:30 a.m.- lying on floor next to bed, bleeding from head, hematoma to right side of head, complained of right shoulder and hip pain. Sent to hospital. *5/30/14 at 3:56 a.m., hydrocodone- acetaminophen 7.5 mg -325 mg -1 tablet by mouth for pain. (no notes describing discomfort.) -4:00 a.m.,- heard alarm , resident lying on the floor on her right side, complained of her right arm hurting, denied hitting head, bruise to her right elbow, continued with ecchymosis (bruising) to her right head and hip from last fall. During an observation on 6/2/14 at 4:10 p.m., Resident #12 was sitting on the side of the bed visiting with friends. During an observation on 6/3/14 at 12:10 p.m., Resident #12 was sitting on the side of her bed, eating lunch, alert with purple bruising noted beneath her right eye. During an interview on 6/3/14 at 3:35 p.m., Resident #12 said she had fallen a few times recently. She denied any medication changes. She said usually her pain scale was "0". She said she had not received therapy in several months. Resident #12 said her mattress had remained the same and denied ever having a mat on the floor. She said when she got sleepy she tried to lie down now, so she would not fall. During an observation 6/4/14 at 1:00 p.m., Resident #12 was sitting on the side of her bed. Her bed alarm was unclipped. She said she did not feel well and rubbed her right chest. She said, "You know I broke that bone." During an interview on 6/4/14 at 9:25 a.m., LVN A said no one had looked at Resident #12's medications as a possible relation to her falls. LVN A said Resident #12 knew her last pain medication was administered at 11:00 p.m. She said Resident #12 usually requested additional medication before her next scheduled dose at 7:00 a.m. LVN A said when additional PRN pain medications were ordered they had discussed alternatives should be attempted. She said she did not think alternatives were always attempted. LVN A said she had been concerned with the resident's increased medication. During an interview on 6/4/14 at 10:35 a.m., the consultant pharmacist said he had documented in his notes to the DON at the beginning of May 2014 that Resident #12's pain medications, anti-anxiety, muscle relaxant medications may contribute to falls. He said he had given his notes to the ADON. The pharmacy consultant report dated May 1-May7 2014 indicated Resident #12 received oxybutynin chloride (Ditropan/antispasmodic), flavoxate HCL (Urispas/reduces spasms), Lorazepam (anti-anxiety), cyclobenzaprine HCL (Flexeril/muscle relaxant). His note said frequent PRN use noted with Lorazepam and recently Flexeril. He discussed the anticholinergic effects, and potential CNS (central nervous system) effects. His note went on to say how Flexeril had high sedating properties and increased risk of fracture and questionable efficacy when used in the elderly. He mentioned her increased use of her PRN Lorazepam and Hydrocodone/APAP, and the combination of medications could be related to her falls and physical complaints. The pharmacist said the medications with her Coumadin usage could put her at high risk of significant bleeding due to falls. The ADON's written comments regarding pharmacy recommendations dated 5/12/14 included: " ...monitoring her lab work (INRs-international normalization ratio- for Coumadin), monitoring her PRN Flexeril closely and monitoring her Lorazepam per nursing assessments ... " During an interview on 6/4/14 at 10:55 a.m., the ADON said she talked to Resident #12 and she did not want to change her medications. She had reviewed her medications after her falls but did not change anything. The ADON said nursing had offered her non-pharmacologic alternatives prior to medicating Resident #12. The ADON could not provide documentation on her care plan, nursing notes, assessments or other nursing records that Resident #12's medications had been reviewed; alternatives to medications had been tried or medication reductions had been attempted. An undated fall prevention and management program policy said " ...a fall prevention program would be established and maintained to assess all residents to determine their risks for falls ... A plan of care would be implemented based on the resident's assessed needs.... An intervention said to monitor and reduce medications when appropriate ... " The United States National Library of Medicine National Institutes of Health, pub med, www.ncbi.nlm.nih.gov/pubmed/ 204 y accessed on 6/5/14 indicated indicated " ...However, elderly patients who are deemed to be at risk of falls are often not started on warfarin therapy secondary to a perceived higher risk of bleeding complications... " 2. Electronic physician orders [REDACTED].#19 was [AGE] years old admitted [DATE] with a [DIAGNOSES REDACTED]. The most recent care plan dated 5/30/14 indicated Resident #19 was a fall risk, had limited range of motion, had cognitive deficit for decision making as evidenced by being disoriented to place and time, and impaired physical mobility. It did not mention not leaving the resident alone. The fall risk assessment dated [DATE] indicated Resident #19's cognition was mildly/moderately impaired, and she scored a 10 on the assessment which indicated a high risk for falls. The admission assessment dated [DATE] indicated Resident #19 was alert with disorganized thinking and disoriented to person and time. She required extensive assist with ADLs, had shingles, and decreased movement to the right upper extremity and left lower extremity. During an interview on 6/4/14 at 1:10 p.m. Resident #19`s family member said Resident #19 was in a local rehab hospital prior to admission to the facility but could not keep up with the therapy. Resident #19`s family member said Resident #19 declined and became more confused while at the rehab hospital. Resident #19's family member said Resident #19 did not have the strength to sit up by herself or feed herself. An incident/accident report dated 6/2/14 indicated Resident #19 was up in her wheelchair and slid to the floor unwitnessed. Resident #19 did not sustain any injuries. During an interview on 6/2/14 at 2:15 p.m., LVN A said COTA HH was in Resident #19's room working with her. LVN A said COTA HH left Resident #19 alone in her wheelchair and she fell out of her wheelchair. LVN A said she would not have left Resident #19 alone in a wheelchair. During an interview on 6/2/14 at 2:20 p.m., COTA HH said she was working with Resident #19 on her ADLs. She said she assisted Resident #19 to a wheelchair to sit up to eat. COTA HH said before she left the room she placed a wheelchair alarm on Resident #19' s clothing and attached her call light to the wheelchair. COTA HH said she placed a bed side table in front of Resident #19 before she left the room. COTA HH said Resident #19 kept saying she wanted to go home. COTA HH said she told RN E and CNA B Resident #19 was sitting up in a wheelchair after she left the room. During an interview on 6/2/14 at 2:25 p.m., RN E said Resident #19 fell from her wheelchair to the floor. RN E said when he entered Resident #19's room the chair alarm was not sounding. RN E said Resident #19 was confused. During an interview on 6/4/14 at 9:15 a.m., COTA HH said she and RN E tested the chair alarm prior to placing it on Resident #19. The COTA said she felt safe leaving Resident #19 up and unattended in a wheelchair. During an interview on 6/4/14 at 9:25 a.m., RN E said another resident's family member alerted him Resident #19 had fallen. RN E said when he entered Resident #19's room she was lying in the floor with her wheelchair straddling her and she was yelling. RN E said he felt Resident #19 would be fine to be left up and alone in a wheelchair. During an interview on 6/4/14 at 9:37 a.m., RN F said Resident #19 was unaware of her surrounding and situation. She said Resident #19 was confused a lot. RN F said it would be unsafe to leave Resident #19 alone in a wheelchair. During an interview on 6/4/14 at 9:45 a.m., LVN A said she told the COTA HH it would not be a good idea to put Resident #19 in a wheelchair and leave her alone. LVN A said Resident #19 was confused and agitated when the COTA HH was working with her. During an interview on 6/4/14 at 9:55 a.m., RN G said Resident #19's cognition was severely impaired. During an interview on 6/4/14 at 10:05 a.m., CNA D said Resident #19 was confused and yelled out. She said she would not leave Resident #19 alone in a wheelchair. During an interview on 6/4/14 at 10:40 a.m., CNA J said Resident #19 was confused and required total assistance with all ADLs. CNA J said she would not leave Resident #19 alone in a wheelchair. During an interview on 6/4/14 at 1:30 p.m., the DON said Resident #19 fell from her wheelchair. She said she was conducting an investigation. The DON said Resident #19 came to her facility because she was unable to keep up with the therapy provided at the rehab hospital. 3. During an observation on 6/1/14 at 10:12 a.m., the lavatory (sink) water temperature in Resident #9's room (301) was 116.5 degrees F. During observations on 6/2/14 the following water temperatures were noted: *9:55 a.m. - Hall 200 sink in the shower room water temperature was 116.2 F. *10:00 a.m. - Hall 100 shower water temperature was 117.4 F. *10:05 a.m. - Room 301 lavatory temperature was 110.1 F. *10:15 a.m. - Room 308 lavatory temperature was 110.3 F. During an interview on 6/2/14 at 10:50 a.m., the maintenance supervisor said he tried to keep the residents' lavatory and shower water temperatures between 106 and 108 F. He said the temperatures would be within the appropriate range one day and would be above range the next. He said water temperatures were hard to control. During observation on 6/3/14 the following water temperatures were noted: *10:40 a.m. - Room 102 lavatory water temperature was 112.5 F. *10:50 a.m. - Room 401 lavatory water temperature was 111.4 F. *10:53 a.m. - Room 312 lavatory water temperature was 121.2 F. A Quarterly MDS dated [DATE] indicated Resident # 26 could make herself understood and could understand others. (Resident #26 resided on hall 300) During an interview on 6/3/14 at 1:30 p.m., Resident #26 said the shower water on her hall was too hot. Resident #26 said she asked the CNA assisting her with the shower to cool it off. Resident #26 said they needed to get the water temperature down. A Quarterly MDS dated [DATE] indcated Resident #27 could make herself understood and could understand others. (Resident #27 resided on hall 300) During an interview on 6/3/14 at 1:30 p.m., Resident #27 said the shower water was too hot. She said they had a hard time regulating it during showers to get the right temperature. A Quarterly MDS dated [DATE] indicated Resident #24 could make herself understood and could understand others. (Resident #24 resided on hall 300) During an interview on 6/3/14 at 1:43 p.m., Resident #24 said the shower water was too hot. She said at times she was afraid she would get scalded. She said the last time it was too hot was on Saturday 5/31/14. She said she told the maintenance supervisor about it, and he told her he had trouble regulating the water all over the building and he would fix it. A Quarterly MDS dated [DATE] indicated Resident #25 could make herself understood and could understand others. (Resident #25 resided on hall 300) During an interview on 6/3/14 at 1:50 p.m., Resident #25 said the shower water was too hot. She said she knew you could get scalded, so she tried to "watch it." During an interview on 6/3/14 at 2:45 p.m., the maintenance supervisor said he checked water temperatures every day at the hot water heater and checked water temperatures in rooms on Fridays. He said he thought the temperature could be 105-115 degrees F. He said the mixing valves fluctuated and he did not know they would exceed 110 degrees F. During an interview on 6/1/14 at 10:15 a.m., CNAs C and JJ said the water in the shower rooms did get hot and they were careful to adjust it when it was too hot for the residents The maintenance logged water temperatures test reports from January- May 2014 indicated the water temperatures in the lavatories and showers to be from 106 F to 107 F. During an interview on 6/4/14 at 2:00 p.m., the administrator said the residents' hall water temperatures were checked weekly. She said she thought different halls were checked each week. The administrator said she did not review the monthly water test reports. She said she reviewed the January- May 2014 water test reports and said, all the water temperatures were the same month to month with no variance. She said she had no idea there was any problem with the water temperatures on the halls and denied complaints from residents or staff. An undated hot water temperature policy said " ...resident use hot water would be reliably controlled, such as by thermostatic or mixing valves to not exceed 110 degrees Fahrenheit ... " The ADON on 6/4/14 at 3:30 p.m. provided a list indicating the census was 88 and 81 residents were at high risk for falls.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the comprehensive assessment to ensure services to restore as much bladder function as possible for 1 of 3 residents reviewed for indwelling (Foley) catheters. (Resident #8) Resident #8's Foley catheter tubing was not secured to prevent pulling and tension. Resident #8 sustained significant penile erosion (breakdown of tissue at the catheter insertion site) that resulted in tissue trauma (penile tear) measuring 5 centimeters (cm) from the urethral opening down, and 3.5 (cm) across, the penile shaft. Resident #8's Foley catheter was changed by RN O on 4/3/14 and 5/3/14. LVN P changed his catheter on 3/4/14 and 6/2/14. The nurses did not document an assessment or treatment of [REDACTED]. This failure could place 5 residents with Foley catheters at risk for discomfort, urethral trauma and UTIs. Findings included: Electronic physician orders [REDACTED].#8, was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#8 had a Foley catheter to gravity and catheter care. The most recent MDS assessment dated [DATE] indicated Resident #8 was understood, understands, required extensive assistance with ADLs and had a catheter. The interim care plan on admitted d 2/4/14 indicated Resident #8 had a Foley catheter, but did not address the penile tear. The comprehensive care plan dated 5/19/14 did not address Resident #8's Foley catheter use, penile tear, or behaviors related to pulling on the catheter tubing. A history and physical dated 2/14/14 by Resident #8's primary physician did not indicate a penile tear. A nurse note 2/4/14 did not indicate a penile tear or any abnormal findings to the penis. A skin data sheet dated 5/26/14 under category location of wounds did not indicate a penile injury. During an observation and interview with LVN K on 6/1/14 at 10:18 a.m., Resident #8 was in bed and did not have his catheter tubing secured. LVN K said the catheter tubing should be secured. LVN K said Resident #8's penile tear occurred shortly after admission. LVN K said she reported the penile tear to the treatment nurse. She said she did not notify the physician. During an observation and interview with LVN X on 6/1/14 at 3:15 p.m., Resident #8 was lying in bed. LVN X said there was a skin tear horizontal and vertically down the shaft and base of Resident #8's penis, with a moderate amount of white foul smelling discharge on the penis and scrotum, and yellow-green colored urine in the catheter collection bag. LVN X said she did not know when the penile tear occurred. During an interview on 6/1/14 at 3:20 p.m., RN G said Resident #8 admitted with penile erosion (breakdown of tissue at the catheter insertion site) She said she recalled treating the area with triple antibiotic ointment in the past, but did not document it or consult with the physician. During an interview on 6/2/14 at 2:15 p.m., CNA L said she remembered the tear to Resident #8's penis occurred after admission. CNA L said she reported the tear to the charge nurse. During an interview on 6/2/14 at 4:30 p.m., RN E said Resident #8's Foley catheter had been changed on 3/4/14, 4/3/14, 5/3/14, and 6/2/14. RN E said the penile tear was not documented with the above catheter changes. During an interview on 6/2/14 at 4:38 p.m., RN O said she changed Resident #8's Foley catheter on 4/3/14 and 5/3/14. She said she did not see a penile tear. During an interview on 6/2/14 at 4:43 p.m., LVN P said she changed Resident #8's Foley catheter on 3/4/14 and 6/2/14. She denied seeing a penile tear. During an interview on 6/3/14 at 9:18 a.m., CNA N said she was aware of Resident #8's penile tear. She said she thought she reported it to the charge nurse about one month after his admission. During an interview on 6/3/14 at 10:02 a.m., the DON said she expected the treatment nurse to document abnormal findings on admission in the nursing notes, call the physician and the family. The DON said she was unable to locate documentation in Resident #8's clinical record of a penile tear on admission or prior to admission. During an observation on 6/3/14 at 1:40 p.m., RN G measured Resident #8 ' s penile tear. She said the tear was 5 centimeters (cm) long from the urethra down the shaft and 3.5 (cm) wide with redness noted at 9 o'clock with a scant amount of bleeding. During an interview on 6/3/14 at 4:35 p.m., NP R said she was "just made aware" of the penile tear after surveyor intervention. She said she examined the area prior to this interview. NP R said this type of tear was from catheter trauma. She said she would have examined the trauma if she had of been notified. NP R said she made new recommendations. NP R said this area of concern should have been documented. During an interview on 6/4/14 at 11:40 a.m., the DON said there had been no attempts to remove Resident #8's Foley catheter since admission. She said Resident # 8's penile tear "had been noticed, but no one thought it worth documenting about. " She said the physician was not notified of the penile tear. A nurse note dated 6/1/14 indicated after notification from the facility Resident #8's physician arrived at the facility to examine the penile tear. A progress note dated 6/1/14 indicated Resident #8's physician indicated a penile tear upon examination. A nurse note, written by RN G, with a computer entry date of 6/2/14 at 9:12 a.m., indicated a late entry for 2/10/14. The note indicated Resident #8 had a torn meatus with skin flaps to head of penis, scar tissue present to urethra, small amount of bloody drainage noted to catheter site and monitoring for further injury. A nurse note dated 6/3/14 indicated Resident #8 had redness at 9 o'clock on the penile tear. The physician was notified and new orders were obtained to clean site with normal saline, apply [MEDICATION NAME] ointment daily, collect a urinalysis with culture, and [MEDICATION NAME] 500 milligram (mg) daily. A policy and procedure Change in a Resident's Condition or Status dated 4/2007 indicated " ...the nurse should notify the physician when there is an accident or incident, a significant change in condition in status that will not normally resolve itself without intervention without clinical interventions. The nurse would record in the medical record information relative to the changes in the resident's medical/mental condition or status ... " The website, <http://www.public.asu.edu/~cbaldwi1/swborderlands/Stabilizing_the_Urinary_Catheter.pdf>, accessed 6/6/14, read "The indwelling urinary catheter is secured or stabilized to prevent accidental removal, reduce trauma to the urethra and bladder, and reduce inflammation of urinary tissues. The goal of stabilization is to prevent excessive pull or traction on the catheter...The lower abdomen site is preferred for long-term use of catheters for men as it reduces the tissue damage to the urethra." The CMS 672 dated 6/1/14 indicated the census was 88.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the comprehensive assessment to ensure 1 of 3 residents reviewed for indwelling (Foley) catheters (Resident #8) maintained the highest practicable physical and mental well-being. Resident #8's Foley catheter tubing was not secured to prevent pulling and tension. Resident #8 sustained significant penile erosion (breakdown of tissue at the catheter insertion site) that resulted in tissue trauma (penile tear) measuring 5 centimeters (cm) from the urethral opening down, and 3.5 (cm) across, the penile shaft. Resident #8 ' s Foley catheter was changed by RN O on 4/3/14 and 5/3/14. LVN P changed his catheter on 3/4/14 and 6/2/14. The facility did not secure the catheter, assess, provide treatment for, initiate measures to prevent further damage, or consult with the physician until 6/2/14 after surveyor intervention. This failure could place 5 residents with Foley catheters at risk for discomfort, urethral trauma, and UTIs. Findings included: Electronic physician orders [REDACTED].#8, was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#8 had a Foley catheter to gravity and catheter care. The most recent MDS assessment dated [DATE] indicated Resident #8 was understood, understands, required extensive assistance with ADLs and had a catheter. The interim care plan on admitted d 2/4/14 indicated Resident #8 had a Foley catheter, but did not address the penile tear. The comprehensive care plan dated 5/19/14 did not address Resident #8's Foley catheter use, penile tear, or behaviors related to pulling on the catheter tubing. A history and physical dated 2/14/14 by Resident #8's primary physician did not indicate a penile tear. A nurse note 2/4/14 did not indicate a penile tear or any abnormal findings to the penis. A skin data sheet dated 5/26/14 under category location of wounds did not indicate a penile injury. During an observation and interview with LVN K on 6/1/14 at 10:18 a.m., Resident #8 was in bed and did not have his catheter tubing secured. LVN K said the catheter tubing should be secured. LVN K said Resident #8's penile tear occurred shortly after admission. LVN K said she reported the penile tear to the treatment nurse. She said she did not notify the physician. During an observation and interview with LVN X on 6/1/14 at 3:15 p.m., Resident #8 was lying in bed. LVN X said there was a skin tear horizontal and vertically down the shaft and base of Resident #8's penis, with a moderate amount of white foul smelling discharge on the penis and scrotum, and yellow-green colored urine in the catheter collection bag. LVN X said she did not know when the penile tear occurred. During an interview on 6/1/14 at 3:20 p.m., RN G (treatment nurse) said Resident #8 was admitted with penile erosion (breakdown of tissue at the catheter insertion site) She said she recalled treating the area with triple antibiotic ointment in the past, but did not document it or consult with the physician. During an interview on 6/2/14 at 2:15 p.m., CNA L said she remembered the tear to Resident #8's penis occurred after admission. CNA L said she reported the tear to the charge nurse. During an interview on 6/2/14 at 4:30 p.m., RN E said Resident #8's Foley catheter had been changed on 3/4/14, 4/3/14, 5/3/14, and 6/2/14. RN E said the penile tear was not documented with the above catheter changes. During an interview on 6/2/14 at 4:38 p.m., RN O said she changed Resident #8's Foley catheter on 4/3/14 and 5/3/14. She said she did not see a penile tear. During an interview on 6/2/14 at 4:43 p.m., LVN P said she changed Resident #8's Foley catheter on 3/4/14 and 6/2/14. She denied seeing a penile tear. During an interview on 6/3/14 at 9:18 a.m., CNA N said she was aware of Resident #8's penile tear. She said she thought she reported it to the charge nurse about one month after his admission. During an interview on 6/3/14 at 10:02 a.m., the DON said she expected the treatment nurse to document abnormal findings on admission in the nursing notes, call the physician and the family. The DON said she was unable to locate documentation in Resident #8's clinical record of a penile tear on admission or prior to admission. During an observation on 6/3/14 at 1:40 p.m., RN G measured Resident #8's penile tear. She said the tear was 5 centimeters (cm) long from the urethra down the shaft and 3.5 (cm) wide with redness noted at 9 o'clock with a scant amount of bleeding. During an interview on 6/3/14 at 4:35 p.m., NP R said she was "just made aware" of the penile tear after surveyor intervention. She said she examined the area prior to this interview. NP R said this type of tear was from catheter trauma. She said she would have examined the trauma if she had of been notified. NP R said she made new recommendations. NP R said this area of concern should have been documented. During an interview on 6/4/14 at 11:40 a.m., the DON said there had been no attempts to remove Resident #8's Foley catheter since admission. She said Resident # 8's penile tear "had been noticed, but no one thought it worth documenting about. " She said the physician was not notified of the penile tear. A nurse note dated 6/1/14 indicated after notification from the facility Resident #8's physician arrived at the facility to examine the penile tear. A progress note dated 6/1/14 indicated Resident #8's physician indicated a penile tear upon examination. A nurse note, written by RN G, with a computer entry date of 6/2/14 at 9:12 a.m., indicated a late entry for 2/10/14. The note indicated Resident #8 had a torn meatus with skin flaps to head of penis, scar tissue present to urethra, small amount of bloody drainage noted to catheter site and monitoring for further injury. A nurse note dated 6/3/14 indicated Resident #8 had redness at 9 o'clock on the penile tear. The physician was notified and new orders were obtained to clean site with normal saline, apply [MEDICATION NAME] ointment daily, collect a urinalysis with culture, and [MEDICATION NAME] 500 milligram (mg) daily. A policy and procedure Change in a Resident's Condition or Status dated 4/2007 indicated " ...the nurse should notify the physician when there is an accident or incident, a significant change in condition in status that will not normally resolve itself without intervention without clinical interventions. The nurse would record in the medical record information relative to the changes in the resident's medical/mental condition or status ... " The website, <http://www.public.asu.edu/~cbaldwi1/swborderlands/Stabilizing_the_Urinary_Catheter.pdf>, accessed 6/6/14, read "The indwelling urinary catheter is secured or stabilized to prevent accidental removal, reduce trauma to the urethra and bladder, and reduce inflammation of urinary tissues. The goal of stabilization is to prevent excessive pull or traction on the catheter...The lower abdomen site is preferred for long-term use of catheters for men as it reduces the tissue damage to the urethra." The CMS 672 dated 6/1/14 indicated the census was 88.

Based on interview and record review the facility failed to ensure 2 of 2 RNs (RNs O and G) and 1 of 1 LVN ( LVN P) provided services to meet professional standards of quality for 2 of 3 residents reviewed for change in condition. (Residents #s 1 and 8) RN Q did not document an assessment of Resident #1's leg that was bent behind her, and allowed CNAs U and H to reposition the leg causing a spiral fracture. Resident #8 sustained significant penile erosion (breakdown of tissue at the catheter insertion site) that resulted in tissue trauma (penile tear) measuring 5 centimeters (cm) from the urethral opening down, and 3.5 (cm) across, the penile shaft. Resident #8's indwelling urinary catheter (Foley) catheter was changed by RN O on 4/3/14 and 5/3/14. LVN P changed his catheter on 3/4/14 and 6/2/14. The nurses did not document an assessment or treatment of [REDACTED]. This failure could place the census of 88 residents at risk for not receiving care and services to protect their rights, meet their needs or ensure safety. Findings included: 1. Electronic physician orders [REDACTED].#1 was [AGE] years old, originally admitted on [DATE], and re-admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] did not address Resident #1's cognitive impairment related to her dementia. The MDS indicated she required extensive assistance with transfers, dressing, and personal hygiene. An incident report dated 5/23/14 at 8:40 a.m., indicated the nurse was called to Resident #1's room after the CNA found the resident's upper right leg swollen. There was no evidence of trauma noted. The CNA reported Resident #1 complained of pain while being repositioned. NP R was notified and ordered an X-ray. At 4:39 p.m., Resident #1's primary care physician was informed Resident #1's broken femur and ordered the resident be sent to the hospital for treatment and evaluation. A provider investigation report dated 5/23/14 indicated Resident #1 complained of pain to leg while being dressed. Resident #1's right leg was noted to be swollen without bruising and her skin was warm, dry and intact. The report indicated on 5/22/14 CNAs U and H noticed Resident #1's right knee was in an awkward position and notified RN Q. RN Q assessed Resident #1's leg and noted it was swollen, without outward signs of trauma. The report indicated RN Q said she felt Resident #1's knee was simply "stiff " from being in an awkward position. RN Q allowed the CNAs to continue providing care. The CNAs lifted Resident #1's leg to straighten out the leg when CNA U reported hearing an audible "pop. " CNA H and RN Q denied hearing a "pop." According to the report Resident #1 was resistive to care and complained of pain. The report indicated the investigation was inconclusive as to how Resident #1's knee/leg came to be in the awkward position. The report indicated it was likely Resident #1's leg was broken when the CNAs straightened the leg and the injury exacerbated during the care. Resident #1's fracture occurred just below her previous hip replacement device. The report contained information from Medscape titled Periprosthetic Fractures indicating "... the original placement of an implant may predispose a person to a later fracture and the long term presence of a device may change the structure of a bone and increase the susceptibility to fracture ... " Nurses' notes dated May 2014 indicated no documented assessment of Resident #1's leg on May 22, 2014. Nurses' notes dated 5/23/14 indicated RN S assessed Resident #1's leg and noted increased swelling and pain. NP R was notified with new orders received to obtain an upper right leg x-ray. At 4:40 p.m., the physician was notified of Resident #1's broken femur and ordered the resident to be sent to the hospital for treatment and evaluation. An x-ray report dated 5/23/14 indicated Resident #1 had a moderately displaced oblique fracture extending from the mid distal 3rd of femoral shaft. An x-ray report dated 5/23/14 from the hospital indicated Resident #1 had a mid shaft spiral fracture. During an interview on 6/2/14 at 11:00 a.m., the DON said CNA U should have asked her coworkers if they heard the "pop" when Resident #1's leg was repositioned. She said Resident #1could move herself in bed and assisted with transfers prior to the incident. The DON said RN Q should have documented her assessment of Resident #1's leg. During an interview on 6/2/14 at 11:15 a.m., CNA B said she worked with Resident #1 on 5/22/14 and 5/23/14. She said she did not notice any abnormalities with Resident #1's legs prior to the end of her shift on 5/22/14. She said she noticed the swelling and different appearance in Resident #1's leg the morning of 5/23/14 and immediately reported to the charge nurse. During an interview on 6/2/14 at 2:15 p.m., CNA U said she and CNA H went to Resident #1's room around 9:00 p.m. on 5/22/14 to get the resident ready for bed. She said when they pulled back the sheet they noticed Resident #1's knee was bent and her right heel pointed back towards her buttocks. CNA U said they immediately notified RN Q and did not move the leg until the nurse gave her approval to move the leg. CNA U said the Resident #1 did not seem to be in any pain. During an interview on 6/2/14 at 3:45 p.m., CNA H said she and CNA U went into Resident #1's room around 9:00 p.m. on 5/22/14 to get the resident ready for bed. When the cover was pulled back they noticed Resident #1's leg was bent with her heel pointing towards her buttocks. CNA H said they immediately notified RN Q and did not move the leg until the nurse assessed the leg and gave her approval to continue with care. CNA H said she did not hear a "pop" sound. She said Resident #1 did not exhibit signs of pain and said Resident #1 often resisted care. During an interview on 6/3/14 at 9:50 a.m., RN Q said she assessed Resident #1's leg on 5/22/14. She said ....she did not know why she did not document her assessment in Resident #1's nurses' notes on 5/22/14. She did not hear a " pop" and did not notify the physician. 2. Electronic physician orders [REDACTED].#8, was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#8 had a Foley catheter to gravity and catheter care. The most recent MDS assessment dated [DATE] indicated Resident #8 was understood, understands, required extensive assistance with ADLs and had a catheter. The interim care plan on admitted d 2/4/14 indicated Resident #8 had a Foley catheter, but did not address the penile tear. The comprehensive care plan dated 5/19/14 did not address Resident #8's Foley catheter use, penile tear, or behaviors related to pulling on the catheter tubing. A history and physical dated 2/14/14 by Resident #8's primary physician did not indicate a penile tear. A nurse note 2/4/14 did not indicate a penile tear or any abnormal findings to the penis. A skin data sheet dated 5/26/14 under category location of wounds did not indicate a penile injury. During an observation and interview with LVN K on 6/1/14 at 10:18 a.m., Resident #8 was in bed and did not have his catheter tubing secured. LVN K said the catheter tubing should be secured. LVN K said Resident #8's penile tear occurred shortly after admission. LVN K said she reported the penile tear to the treatment nurse. She said she did not notify the physician. During an observation and interview with LVN X on 6/1/14 at 3:15 p.m., Resident #8 was lying in bed. LVN X said there was a skin tear horizontal and vertically down the shaft and base of Resident #8's penis, with a moderate amount of white foul smelling discharge on the penis and scrotum, and yellow-green colored urine in the catheter collection bag. LVN X said she did not know when the penile tear occurred. During an interview on 6/1/14 at 3:20 p.m., RN G said Resident #8 admitted with penile erosion (breakdown of tissue at the catheter insertion site) She said she recalled treating the area with triple antibiotic ointment in the past, but did not document it or consult with the physician. During an interview on 6/2/14 at 2:15 p.m., CNA L said she remembered the tear to Resident #8's penis occurred after admission. CNA L said she reported the tear to the charge nurse. During an interview on 6/2/14 at 4:30 p.m., RN E said Resident #8's Foley catheter had been changed on 3/4/14, 4/3/14, 5/3/14, and 6/2/14. RN E said the penile tear was not documented with the above catheter changes. During an interview on 6/2/14 at 4:38 p.m., RN O said she changed Resident #8's Foley catheter on 4/3/14 and 5/3/14. She said she did not see a penile tear. During an interview on 6/2/14 at 4:43 p.m., LVN P said she changed Resident #8's Foley catheter on 3/4/14 and 6/2/14. She denied seeing a penile tear. During an interview on 6/3/14 at 9:18 a.m., CNA N said she was aware of Resident #8's penile tear. She said she thought she reported it to the charge nurse about one month after his admission. During an interview on 6/3/14 at 10:02 a.m., the DON said she expected the treatment nurse to document abnormal findings on admission in the nursing notes, call the physician and the family. The DON said she was unable to locate documentation in Resident #8's clinical record of a penile tear on admission or prior to admission. During an observation on 6/3/14 at 1:40 p.m., RN G measured Resident #8's penile tear. She said the tear was 5 centimeters (cm) long from the urethra down the shaft and 3.5 (cm) wide with redness noted at 9 o'clock with a scant amount of bleeding. During an interview on 6/3/14 at 4:35 p.m., NP R said she was "just made aware" of the penile tear after surveyor intervention. She said she examined the area prior to this interview. NP R said this type of tear was from catheter trauma. She said she would have examined the trauma if she had of been notified. NP R said she made new recommendations. NP R said this area of concern should have been documented. During an interview on 6/4/14 at 11:40 a.m., the DON said there had been no attempts to remove Resident #8's Foley catheter since admission. She said Resident # 8's penile tear "had been noticed, but no one thought it worth documenting about. " She said the physician was not notified of the penile tear. A nurse note dated 6/1/14 indicated after notification from the facility Resident #8's physician arrived at the facility to examine the penile tear. A progress note dated 6/1/14 indicated Resident #8's physician indicated a penile tear upon examination. A nurse note written by RN G with a computer entry date of 6/2/14 at 9:12 a.m., indicated a late entry for 2/10/14. The note indicated Resident #8 had a torn meatus with skin flaps to head of penis, scar tissue present to urethra, small amount of bloody drainage noted to catheter site and monitoring for further injury. A nurse note dated 6/3/14 indicated Resident #8 had redness at 9 o'clock on the penile tear. The physician was notified and new orders were obtained to clean site with normal saline, apply [MEDICATION NAME] ointment daily, collect a urinalysis with culture, and [MEDICATION NAME] 500 milligram (mg) daily. A policy and procedure Change in a Resident's Condition or Status dated 4/2007 indicated the nurse should notify the physician when there is an accident or incident, a significant change in condition in status that will not normally resolve itself without intervention without clinical interventions. The nurse would record in the medical record information relative to the changes in the resident's medical/mental condition or status. A policy and procedure Change in a Resident's Condition or Status dated 4/2007 indicated "...the nurse should notify the physician when there is an accident or incident, a significant change in condition in status that will not normally resolve itself without intervention without clinical interventions. The nurse would record in the medical record information relative to the changes in the resident's medical/mental condition or status..." The Administrative code Title 22 Examinig Boards Part 11 Texas Board of Nursing Chapter 217 Licensure, Peer Assistance and Practice Rule 217.11 Standards of Nursing Practice at http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&ti=22&ch=217&rl=11 accessed on 6/12/14 indicated "...The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; ..." The CMS 672 dated 6/1/14 indicated a census of 88.

Based on observation, interview, and record review, the facility failed to consult with the physician regarding an injury for 1 of 3 residents reviewed for use of a indwelling urinary catheter (Foley) catheter. (Resident #8) Resident #8 sustained significant penile erosion (breakdown of tissue at the catheter insertion site) that resulted in tissue trauma (penile tear) measuring 5 centimeters (cm) from the urethral opening down, and 3.5 (cm) across, the penile shaft. Resident #8's Foley catheter was changed by RN O on 4/3/14 and 5/3/14. LVN P changed his catheter on 3/4/14 and 6/2/14. The facility did not secure the catheter, assess, provide treatment for, initiate measures to prevent further damage, or consult with the physician until 6/2/14 after surveyor intervention. This failure could place the census of 88 residents at risk for changes of condition with a delay in medical evaluation and treatment. Findings included: Electronic physician orders [REDACTED].#8, was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#8 had a Foley catheter to gravity and catheter care. The most recent MDS assessment dated [DATE] indicated Resident #8 was understood, understands, required extensive assistance with ADLs and had a catheter. The interim care plan on admitted d 2/4/14 indicated Resident #8 had a Foley catheter, but did not address the penile tear. The comprehensive care plan dated 5/19/14 did not address Resident #8's Foley catheter use, penile tear, or behaviors related to pulling on the catheter tubing. A history and physical dated 2/14/14 by Resident #8's primary physician did not indicate a penile tear. A nurse note 2/4/14 did not indicate a penile tear or any abnormal findings to the penis. A skin data sheet dated 5/26/14 under category location of wounds did not indicate a penile injury. During an observation and interview with LVN K on 6/1/14 at 10:18 a.m., Resident #8 was in bed and did not have his catheter tubing secured. LVN K said the catheter tubing should be secured. LVN K said Resident #8's penile tear occurred shortly after admission. LVN K said she reported the penile tear to the treatment nurse. She said she did not notify the physician. During an observation and interview with LVN X on 6/1/14 at 3:15 p.m., Resident #8 was lying in bed. LVN X said there was a skin tear horizontal and vertically down the shaft and base of Resident #8's penis, with a moderate amount of white foul smelling discharge on the penis and scrotum, and yellow-green colored urine in the catheter collection bag. LVN X said she did not know when the penile tear occurred. During an interview on 6/1/14 at 3:20 p.m., RN G said Resident #8 admitted with penile erosion (breakdown of tissue at the catheter insertion site) She said she recalled treating the area with triple antibiotic ointment in the past, but did not document it or consult with the physician. During an interview on 6/2/14 at 2:15 p.m., CNA L said she remembered the tear to Resident #8's penis occurred after admission. CNA L said she reported the tear to the charge nurse. During an interview on 6/2/14 at 4:30 p.m., RN E said Resident #8's Foley catheter had been changed on 3/4/14, 4/3/14, 5/3/14, and 6/2/14. RN E said the penile tear was not documented with the above catheter changes. During an interview on 6/2/14 at 4:38 p.m., RN O said she changed Resident #8's Foley catheter on 4/3/14 and 5/3/14. She said she did not see a penile tear. During an interview on 6/2/14 at 4:43 p.m., LVN P said she changed Resident #8's Foley catheter on 3/4/14 and 6/2/14. She denied seeing a penile tear. During an interview on 6/3/14 at 9:18 a.m., CNA N said she was aware of Resident #8's penile tear. She said she thought she reported it to the charge nurse about one month after his admission. During an interview on 6/3/14 at 10:02 a.m., the DON said she expected the treatment nurse to document abnormal findings on admission in the nursing notes, call the physician and the family. The DON said she was unable to locate documentation in Resident #8's clinical record of a penile tear on admission or prior to admission. During an observation on 6/3/14 at 1:40 p.m., RN G measured Resident #8's penile tear. She said the tear was 5 centimeters (cm) long from the urethra down the shaft and 3.5 (cm) wide with redness noted at 9 o'clock with a scant amount of bleeding. During an interview on 6/3/14 at 4:35 p.m., NP R said she was "just made aware" of the penile tear after surveyor intervention. She said she examined the area prior to this interview. NP R said this type of tear was from catheter trauma. She said she would have examined the trauma if she had of been notified. NP R said she made new recommendations. NP R said this area of concern should have been documented. During an interview on 6/4/14 at 11:40 a.m., the DON said there had been no attempts to remove Resident #8's Foley catheter since admission. She said Resident # 8's penile tear "had been noticed, but no one thought it worth documenting about. " She said the physician was not notified of the penile tear. A nurse note dated 6/1/14 indicated after notification from the facility Resident #8's physician arrived at the facility to examine the penile tear. A progress note dated 6/1/14 indicated Resident #8's physician indicated a penile tear upon examination. A nurse note written by RN G with a computer entry date of 6/2/14 at 9:12 a.m., indicated a late entry for 2/10/14. The note indicated Resident #8 had a torn meatus with skin flaps to head of penis, scar tissue present to urethra, small amount of bloody drainage noted to catheter site and monitoring for further injury. A nurse note dated 6/3/14 indicated Resident #8 had redness at 9 o'clock on the penile tear. The physician was notified and new orders were obtained to clean site with normal saline, apply [MEDICATION NAME] ointment daily, collect a urinalysis with culture, and [MEDICATION NAME] 500 milligram (mg) daily. A policy and procedure Change in a Resident's Condition or Status dated 4/2007 indicated " ...the nurse should notify the physician when there is an accident or incident, a significant change in condition in status that will not normally resolve itself without intervention without clinical interventions. The nurse would record in the medical record information relative to the changes in the resident's medical/mental condition or status ... " The website, <http://www.public.asu.edu/~cbaldwi1/swborderlands/Stabilizing_the_Urinary_Catheter.pdf>, accessed 6/6/14, read "The indwelling urinary catheter is secured or stabilized to prevent accidental removal, reduce trauma to the urethra and bladder, and reduce inflammation of urinary tissues. The goal of stabilization is to prevent excessive pull or traction on the catheter...The lower abdomen site is preferred for long-term use of catheters for men as it reduces the tissue damage to the urethra." The CMS 672 dated 6/1/14 indicated the census was 88.