Every finding on record at Holy Spirit Retirement Home

Based on observation, resident interview, staff interview and policy review the facility failed to provide food at an appetizing temperature when mashed potatoes had a temperature of 125 degrees on the steam table before the lunch meal and had a temperature of 121 degrees for a room tray with 2 of 8 residents reviewed (Resident #24 and #40) that had complained about food temperatures. The facility reported a census of 56 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #40 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 4/27/26 at 1:31 PM Resident #40 stated the food is served cool when it should be warm a couple times a week. Resident #40 stated she does not ask them to heat it up but would like the warm food to be served warm. Resident #40 stated the food should be served warm. 2. Review of Resident #24's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive functioning. Interview 4/27/26 at 3:33 PM with Resident #24 revealed that food is sometimes not hot, and this happens on days that she orders room trays. 3. On 4/29/26 at 12:02 PM an observation of pre-temperatures of the 2nd floor kitchenette steam table included: mashed potatoes at 125 degrees Fahrenheit during lunch service. On 4/29/26 at 12:28 PM an observation revealed Staff C, Dietary Aide using a temperature probe to puncture through the tin foil dated with permanent marker that covered the residents food items on a room tray to obtain the temperature of those items. Temperatures included: Mash Potatoes at 121 degrees Fahrenheit and salisbury steak at 130 degrees Fahrenheit. On 4/29/26 at 2:35 PM Staff E, Certified Dietary Manager (CDM) revealed concerns with the room tray temperatures and steam table pre-serving temperatures. Staff E stated the food temperatures were to be above 135 degrees Fahrenheit. On review of a policy provided by the facility dated 3/29/21 titled, Food Temps P&P documented all hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit.

Based on observations, staff interviews, Electronic Health Record (EHR) review, resident interviews, family interviews, and policy review the facility failed to utilize Enhanced Barrier Precautions (EBP) during wound care for 2 of 4 residents (Residents #50, and #4). The facility further failed to use universal infection control measures (hand hygiene) during catheter care for 2 of 4 residents (Resident #1, and #2). The facility reported a census of 56 residents.Findings Include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief interview for Mental Status (BIMS) of 15 that indicated cognitive mental status. Review of Resident #1's EHR page titled, Order Summary Report revealed an order for a Foley catheter size 16 French with a 10 milliliter balloon to be changed monthly and flush catheter with 60-120 cc of normal saline as needed for urine retention. On 4/29/26 at 1:55 PM an observation revealed Staff F, a Certified Nurse Assistant (CNA) employed for approximately one year with the facility, entered Resident #1's room and explained the procedure to the resident. Staff F applied a gown and gloves without performing hand hygiene. Staff F then retrieved five washcloths, placed them in the sink, and ran water over them, ringing out excess water before placing them on the sink edge. Staff F then took a plastic cylinder and alcohol swabs from a box on the paper towel dispenser and walked to Resident #1's bedside where Resident #1 laid in bed. Staff F pulled down Resident #1's boxers, and initiated peri-care while wearing the original gloves. Staff F then proceeded to wipe the right side of the groin twice with one washcloth. Staff F walked to a trash can, removed a trash bag, and placed the soiled washcloth inside, continuing to wear the same gloves. Staff F performed peri care to the left side of the groin using one washrag and discarded it into the trash bag. Staff F held the catheter at the penis and wiped the catheter tubing twice with the same washcloth, then pulled the resident's boxers back up. Staff F completed the cares using the same gloves to remove an alcohol swab, swabbed the end of the catheter bag, and opened the valve to empty the bag into the cylinder. Staff F used a second alcohol swab to cleanse the end of the catheter bag before closing the valve. Staff F performed no hand hygiene when entering the room, throughout peri-care, or while emptying the catheter leg bag. Staff F helped the resident pull up his jeans and assisted him to stand at the bedside while continuing to wear the same set of gloves. STaff F then retrieved Resident #1's walker, helped pull up Resident #1's jeans and suspenders and proceeded to help Resident #1 into his recliner. STaff F then removed the other washcloths and alcohol swab packaging from the bed and discarded the trash into the trash can. Staff F walked into the restroom with the cylinder, emptied the urine contents into the toilet, and rinsed the cylinder. Staff F at this time then doffed her gloves, removed her gown, and performed hand hygiene. On 4/27/26 at 12:53 PM, Resident #1 revealed that the staff often fail to clean his penis correctly. Resident #1 explained he has a bladder infection, takes antibiotics for a frequent Urinary Tract Infection (UTI). Resident #1 further revealed staff do not wear white gowns when they provide peri care or empty his catheter bag. On 4/29/2026 at 2:05 PM, Staff G Registered Nurse (RN) revealed she has worked at the facility for approximately three years and frequently works with Resident #1. Staff G reported Resident #1 is currently taking an antibiotic (ATB) for a Urinary Tract Infection (UTI) that began on 4/22/26. Staff G explained she monitors the resident for a red and inflamed penis. Staff G stated Resident #1 has never complained to her about needing better penile peri-care before. On 4/29/2026 at 2:19 PM, Staff H, Director of Nursing (DON), expressed concerns regarding the catheter care performed during peri-care on Resident #1. Staff H confirmed she did not perform the procedure correctly, and did not perform hand hygiene as Staff H would expect. Staff H stated she provided education to all CNA staff one week ago, and will provide education again. Staff H acknowledged risk for infection with improper catheter care and peri care during observation. 2. Observation on 04/27/2026 at 12:05 PM of catheter care for Resident #2 showed Staff Q, Certified Nursing Assistant (CNA), gathered supplies, failed to complete hand hygiene, then applied gloves without applying full EBP. The CNA then emptied the leg bag per policy, removed soiled gloves, failed to perform hygiene, then applied new gloves. The CNA discarded urine in the toilet, flushed the toilet, and discarded the urine container into the trash. Next, the CNA changed the garbage bag, removed gloves, failed to complete hand hygiene, shut the bathroom door, exited the resident's room, then closed the door. In an interview on 4/29/26 at 2:31 PM, the Director of Nursing (DON) stated that staff must use EBP for catheter care and perform hand hygiene immediately before and after changing gloves. In an interview on 4/29/26 at 2:31 PM, the Infection Preventionist (IP) reported she provided staff EBP and hand hygiene education but felt overwhelmed by her duties, which prevented her from performing necessary follow-up. 3. The Minimum Data Set (MDS) dated [DATE] for Resident #50 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. MDS also indicated Resident #50 had surgical wounds. On 4/27/26 at 3:37 PM Resident #50 stated she had a small broken bone in her right foot. Resident #50 explained she had a surgical dressing that was changed every 3 days. Resident #50 stated the staff did not wear gowns while they changed the dressing. Observation on 4/27/26 at 3:38 PM revealed no Enhanced Barrier Precaution (EBP) equipment in the room and no EBP sign outside of Resident #50's room. Review of Resident #50's document dated 4/11/26 titled, Discharge Summary documented Resident #50 had 3 surgical wounds to the right ankle. Review of Resident #50's electronic health records documented a physician's order to change band aids to incision 3 times a week. Observation on 4/29/26 at 9:12 AM revealed Staff A, Infection Preventionist / Licensed Practical Nurse (LPN) completed hand hygiene, applied gloves, removed previous dressing on both side of right ankle, 8 sutures on the outer right side top and 1 suture on right side outer right side of right leg with serous drainage on dressing, appeared to have 7 sutures on the inner right ankle, purple bruising to arch of foot and ball of foot, gloves removed, hand hygiene completed, dressing applied to outer right ankle, dressing applied to the inside right ankle, ace wrap applied to the area, 2nd ace wrap applied up to the knee, boot applied to right leg, gloves removed and hand hygiene completed. On 4/29/26 at 12:46 PM the Director of Nursing (DON) stated Resident #50 should have EBP in place. The DON acknowledged Resident #50 had a surgical wound and Resident #50 had some drainage on the bandage and that would require EBP as well. 4. Review of Resident #4 MDS dated [DATE] revealed an admission date of 7/23/25 from a short-term general hospital stay. The MDS further indicated that Resident #4 had surgical wounds. Interview 4/27/26 at 1:02 PM with Resident #4's family member revealed that Resident #4 has an area on her right foot that the facility has been treating for a long time. Review of Resident #4's EHR page titled, Clinical Physician Orders revealed an order for a silver med dressing to be changed daily to Resident #4's right big toe dated 4/1/26. Review of Resident #4's Care Plan with a revision dated of 4/14/26 revealed Resident #4 is on Enhanced Barrier Precautions and for staff to wear a gown and gloves when performing high contact care activities. Observation 4/29/26 at 11:28 AM Staff A Licensed Practical Nurse (LPN) completed hand hygiene and donned gloves. Staff A then was observed to remove Resident #4's sock and shoe. Staff A then removed Resident #4's old bandage from the area on the right foot with the open area to the inside of the right toe. Staff A then doffed her gloves and completed hand hygiene. Staff A then donned new gloves and completed the dressing change per the physician orders. Staff A was observed not wearing a gown while completing the dressing change. Interview 4/29/26 at 11:37 AM with Staff A revealed that she should have been wearing a gown as Resident #4 is on EBP precautions. Interview 4/29/26 at 12:41 PM with the DON revealed she would expect staff to wear gowns for Enhanced Barrier Precautions when doing dressing changes. Review of a facility provided undated policy titled, Enhanced Barrier Precautions indicated staff should be wearing gowns and gloves to prevent contamination of healthcare personnel's hands and clothing during the activities that demonstrate the highest risk of transfer of Multidrug-Resistant Organisms. Review of another facility provided policy titled, Catheter Care dated 4/1/26 indicated staff are to use supplies including a wash basin, towels, gloves, wash clothes, soap and plastic bags. The policy further indicated procedure steps for staff to place a towel on the bedside table as a barrier, hand hygiene, donning gloves with staff to use a clean area/side of the washcloth with every swipe, hold/anchor catheter and cleanse tubing with one swipe aware from meatus to the connection site, do not clean tubing back and forth and to clean away from the body, rinse with warm water in the same order, pat dry, remove towel and complete peri-care if needed, dispose of soiled linens in plastic bag at the foot of the bed, remove gloves and wash hands. Review of a facility provided undated policy titled, Hand Hygiene documented the following list of some of the situations that require hand hygiene included: before and after direct contact with a resident, before and after contact with mucous membranes, body fluids or other excretions, before and after entering isolation precaution settings, before and after assisting a resident with personal care, before and after handling a catheter or other invasive devices, before and after changing a dressing, before and after applying gloves, before and after coming in contact with a resident's skin , after handling soiled or used linens, dressings, bedpans, catheters, and urinals, after handling soiled equipment, surfaces or utensils, after removing personal protective equipment, after having contact with body fluids, wounds or broken skin and after moving contaminated body site to clean body site during resident care delivery.

Based on observations, staff interviews, and policy review, the facility failed to store, prepare, and serve food in accordance with professional standards. The facility did not label and date open food items, follow best-by dates, discard expired food items, perform hand hygiene prior to or during food services, complete hand hygiene when assisting residents with meals, or wear appropriate hair nets during food preparation. The facility reported a census of 56 residents. Findings Include:On 4/27/26 at 11:00 AM, a continuous observation in the kitchen revealed several improperly dated items. The first stand-up refrigerator contained apple juice with an open date of 4/23/26, grape juice with an open date of 4/23/26, and prune juice with an open date of 2/26/26. The second stand-up refrigerator contained red french dressing with an open date of 2/18/26 and salsa with an open date of 2/13/26. The walk-in refrigerator contained an open bag of lettuce without an open or date of delivery. The south pod refrigerator contained a lemonade pitcher with an open date of 4/9/26, grape juice with an open date of 4/9/26, tomato juice with an open date of 4/4/26, and medication pass with an open date of 4/13/26. The dry storage contained items without an open or in date, including a bag of spiral noodles and a bag of elbow noodles.On 4/28/26 at 11:53 AM, an observation revealed Staff B, Dietary Aide, did not complete hand hygiene prior to lunch service. Staff B licked her fingers three times while reviewing meal tickets. After each instance, she continued to grab plates, add food items, and hand plates to staff serving residents without completion of hand hygiene.On 4/29/26 at 12:00 PM, an observation of the drink cart revealed expired food items. The drink cart contained one gallon of chocolate milk with an open date of 4-24-26 and a best-by date of 4-27-26. It also contained grape juice with an open date of 4/23/26 and a best-by date of 1/26/26, and prune juice with an open date of 2/26 and a best-by date of 1/25/26. On 4/29/26 at 12:03 PM, while Staff C, Dietary Aide, served lunch on the second floor unit. The observation revealed multiple staff members entered the kitchenette during the meal service without wearing hair nets. On 4/29/26 at 12:18 PM, an observation revealed Staff D, Certified Nurse Assistant (CNA), assisted two residents with oral intake of the lunch meal without performing hand hygiene beforehand or throughout the meal. Staff D went between the two residents multiple times during the meal without completing hand hygiene. On 4/29/26 at 12:28 PM, an observation revealed Staff C used a temperature probe to puncture through the tin foil with permanent marker with resident room number covering the residents' food items on a room tray to obtain the temperature of those items. Temperatures included Mash Potatoes at 121 degrees Fahrenheit and Steak at 130 degrees Fahrenheit.On 4/27/26 at 11:40 AM, Staff E, Certified Dietary Manager (CDM), stated staff must throw away refrigerator items after three days, and freezer items are acceptable for up to one year after the open date.On 4/28/26 at 12:45 PM, Staff E stated she expects staff to perform proper hand hygiene after the dietary aide licked her fingers and would not want her staff to lick their fingers during food service at any time. She stated refrigerator items are good for three days after the open date and she believed freezer items were acceptable for one year after the open date. Staff E stated she was unsure of the length of time the condiments in the big containers were good for after the open date, but she believed it was a long time.On 4/29/26 at 12:13 PM, Staff C stated that this kitchenette does not have any hair nets and staff must go down to the main kitchen to get a hair net before coming up to the second-floor kitchenette. On 4/29/26 at 2:35 PM, Staff E revealed her concerns about the room tray temperatures, staff entering the kitchenette without proper hairnets, and staff assisting two residents with eating without performing proper hand hygiene. Staff E stated her expectations include staff performing hand hygiene in between assisting multiple residents with feeding each time and wearing hair nets at all times during food service and anytime in the kitchen or kitchenette.On review of an undated policy provided by the facility titled, Storage and Use of Condiments (Open Products), revealed that all opened condiment containers must be properly labeled, stored, and used within defined timeframes. While many condiments are not classified as Time/Temperature Control for Safety (TCS) foods, extended storage after opening may compromise quality, consistency, and resident acceptability. The policy requires staff to document the date opened and keep manufacturer dates visible. The policy mandates staff follow manufacturer guidance for shelf life; if guidance is unavailable, staff must use the item within a 30-60 day timeframe. The rationale documents that extended storage reduces quality and resident satisfaction; timelines support safety and dining experience. On review of an undated policy provided by the facility titled, Hair Restraints in Food Service Areas documented hair restraints are required for all staff involved in food preparation, plating, or direct service of exposed food.On review of an undated policy provided by the facility titled, Hand Hygiene documented the following list of some of the situations that require hand hygiene included: before and after direct contact with a resident, before and after handling food, before and after assisting a resident with meals and after contact with mucous membranes, body fluids or other excretions. On review of a policy provided by the facility dated 2021 titled, Food Storage documented food should be dated as it is placed on the shelf with date marking visible to indicate the date by which it is ready to eat, TCS food should be consumed, sold or discarded. All containers or storage bags must be legible and accurately labeled and dated. All foods should be covered, labeled and dated and routinely monitored to assure that foods will be consumed by their safe use by dates, or frozen or discarded. On review of an undated policy provided by the facility titled, Food Dating and Rotation documented all food items with be labeled with clear date markings and rotated using first in, first out principles. All items removed from original packaging must be dated including month/day/year and also applies to frozen items where original manufacturer date is no longer visible. Monitoring documentation included routine checks for dating and rotation and discard expired or improperly labeled items.

Based on observations, record review and interviews the facility failed to properly use both mechanical stand brakes in a manner that prevented accidents and hazards for 1 of 2 residents reviewed (Resident #21). The facility reported a census of 56 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 documented a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The MDS showed Resident #21 required substantial assistance for transfers. The MDS diagnosis included hip fracture, dementia, and muscle wasting. The Care Plan on 12/3/25 for Resident #21 showed the facility initiated use of a mechanical stand for transfers. Observation on 04/27/2026 at 2:01 PM showed Staff P, Certified Nursing Assistant, applied a sling to Resident #21 then locked the right wheel of the mechanical stand. Using the controls, the CNA lifted the resident from the chair, unlocked the right wheel, then positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. When the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, then lowered the resident. The CNA failed to keep the mechanical stand brakes unlocked during transfer. The Operator's Instructions for the mechanical stand instructed staff to only lock the brakes when raising and lowering the resident during ambulation.In an interview on 4/29/26 at 2:31 PM, the Director of Nursing (DON) reported staff should follow the operator's instructions and keep the wheels unlocked during transfers.

Based on observations, staff interviews, Electronic Health Records (EHR) review, and policy review, the facility failed to maintain a professional standard of quality when staff did not apply the prescribed Thrombo-Embolic Deterrent (TED) hose for Resident #7. The facility reported a census of 56 residents.Findings include: On review of the Minimum Data Set (MDS) dated [DATE] documented Resident #7 had a Brief Interview for Mental Status (BIMS) of 10 that indicated moderate cognitive impairment.On review of EHR titled, Order Summary dated 4/28/26 documented a Physician's Order for Resident #7 knee high TED hose to be applied in the morning and removed in the evening. On review of Resident #7's Treatment Administration Record (TAR) for the month of April documented TED hose to be applied in the morning and removed in the evening. Further review of TAR documented nurse signatures everyday of application and removal.On 4/27/26 at 1:52 PM an observation revealed Resident #7 sitting in the common area watching a movie with white ankle socks present without TED hose noted to be on at this time.On 4/28/26 at 9:18 AM an observation revealed Resident #7 sitting in a recliner without the TED hose present. Resident #7 was wearing white ankle socks. On 4/29/26 at 11:17 AM an observation revealed Resident #7 sleeping in her wheelchair in her room without the TED hose in place. Resident #7 had white ankle socks on at this time.On 4/27/26 at 3:57 PM Resident #7's daughter, stated during a phone interview that her mother should wear TED hose daily and confirmed her belief that Resident #7 needs to wear them every day. Resident #7's daughter confirmed she has never seen her mother wearing them during her visits. On 4/29/26 at 11:23 AM, Staff I, Certified Nurse Assistant (CNA) stated she was assigned to Resident #7's hall today. She reported Resident #7 wore the TED hose occasionally, but the TED hose are sent to the laundry and they do not always return. Staff I stated the pharmacy sends the TED hose, and Resident #7 has been through quite a few pairs this month. She specified Resident #7 has brown and tan TED hose, and staff only applies them if they are in Resident #7's room. Staff I admitted she did not apply the TED hose this morning because none were available in the room, and she did not report the omission to anyone.On 4/29/26 at 11:26 AM, Staff J, CNA reported she frequently worked with Resident #7. Staff J explained the staff sent the TED hose to the laundry, and they did not return. Staff J stated if staff do not find the TED hose present in Resident #7's room staff do not apply them and instead the staff placed regular socks on the resident. On 4/29/26 at 11:28 AM, Staff K, Certified Nurse Assistant (CNA) / bath aide, reported she frequently worked with Resident #7 and provided showers/baths. She stated Resident #7 must wear the TED hose daily, with AM CNAs applying them and PM CNAs removing them. Staff K reported she applied regular socks after Resident #7's shower because she usually does not have the TED hose. She believed the TED hose are not present because staff sends them to the laundry, and they do not return. Staff K estimated she applied the TED hose only two to three times a week.On 4/29/26 12:45 PM an interview with Staff L, Licensed Practical Nurse (LPN) revealed she worked with Resident #7 frequently. Staff L stated the physician order documented the TED hose were to be applied every morning and removed every evening. Staff L stated anyone can apply the TED hose though the nurse is supposed to check and make sure they were applied and / or removed. Staff L stated she checks to make sure before charting if TED hose are present. Staff L explained she does not know if they are frequently missing.On 4/29/26 at 2:20 PM the Director of Nursing (DON) stated nurses must ask CNAs about the TED hose application or removal, and then personally verify the hose's placement. Staff H required nurses to check the TED hose placement before charting and to document the reason for omission if they do not apply the hose. On review of a policy provided by the facility dated 4/01/26 titled, Physician Visits and Medical Orders (task Delegating), documented the members of the interdisciplinary team will provide care, services and treatment according to the most recent medical orders and according to laws, regulations and standards of practice.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents (Resident #3) reviewed for PASRR requirements. The facility reported a census of 56 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of psychotic disorder, depression, and schizophrenia. The MDS for Resident #3 included a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The PASRR Notice of Nursing Facility Approval dated 1/29/14 for Resident #3 indicated the facility failed to resubmit the PASRR with changes that occurred since 2014. The PASRR Notice also failed to indicate what medications were prescribed at the time of approval. The current Clinical Physician Orders for Resident #3 revealed the following medications:On 8/16/22 Venlafaxine extended release 77.5 mg started for treatment of major depressive disorderOn 8/27/25 Quetiapine 300 milligrams (mg) started for treatment of schizoaffective disorder and bipolarThe admission Criteria policy revised March 2019 failed to provide instructions for when a new Level 1 screening must be initiated. In an interview on 4/29/26 at 2:31 PM, the Director of Nursing (DON) reported staff should resubmit a Level I for screening when there are changes in medications. In an interview on 4/29/26 at 2:31 PM, the Infection Preventionist (IP) reported she felt overwhelmed by her duties, which prevented her from catching changes that would require a resubmission of a Level I. The IP acknowledged medications changes have occurred since 2014. The IP stated, I don't know that there have been any behavioral changes. When asked why new medications were ordered, the IP stated, I see what you're saying. I started the resubmission yesterday morning.

Based on observation, Electronic Health Records (EHR) review, resident interview, staff interviews and policy review the facility failed to provide dignity and respect to a resident who wanted a brief change and staff refused to change the brief for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 56 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment.On 4/28/26 at 1:08 PM Resident #3 self propelled down the hallway as she stated she was upset because Staff N, Certified Nurse Assistant (CNA) ripped her brief when she changed the brief and refused to change it.On 4/28/26 at 1:10 PM Staff M, Housekeeping stated Resident #3 said Staff N refused to change her brief after there was a huge rip in the brief. Staff M explained Resident #3 was upset because there was a huge rip in her brief. Staff M asked Resident #3 if she wanted her to get another staff member to change her brief. Staff M asked Staff O, Licensed Practical Nurse (LPN) to help change the ripped brief. Observation on 4/28/26 at 1:15 PM of Staff O assisted Resident #3 with a brief change revealed Staff O completed hand hygiene, applied gloves, removed pants, removed brief, changed Resident #3's brief, Staff O asked Resident #3 if she wanted peri care completed, Resident #3 said yes, Staff O completed personal cares, Staff O removed gloves, completed hand hygiene, applied gloves replace the brief, pulled pants up and assisted Resident #3 to sit down.On 4/28/26 at 1:16 PM an observation of brief change for Resident #3 revealed a large rip to the left side of the brief going around past Resident #3's middle of back. On 4/28/26 at 1:18 PM Resident #3 explained the brief she was wearing with the hole was uncomfortable and that was why she wanted it changed. Resident #3 stated she felt the staff did not provide her with dignity and respect when she asked to have a new brief and Staff N did not change the brief. On 4/28/26 at 1:21 PM Staff O stated she thought Resident #3 reported the staff that did not change her brief was Staff N because she identified the CNA wearing a bandana. Staff O explained Staff M stopped her and talked to her about Resident #3. Staff O stated Staff M stated her brief was ripped and Staff N refused to change the brief. Staff O acknowledged there was a very large hole in the brief when she assisted Resident #3 and changed her brief. Staff O stated Resident #3 was very upset about the incident. Staff O acknowledged Resident #3 stated she did not feel the staff had provided her with dignity or respect when she did not change the brief. Staff O stated Resident #3 did say the brief was uncomfortable and the whole back was ripped. On 4/28/26 at 1:38 PM Staff N, CNA acknowledged she was caring for Resident #3 today. Staff N stated Resident #3 was doing okay but did not get up this morning until 8:00 AM and had been upset ever since. Staff N stated Resident #3 had behaviors at times. Staff N stated if Resident #3 sleeps in then she will probably have a behavior that day. Staff N stated she got Resident #3 dressed that morning and had toileted her after every meal. Staff N stated she had just toileted her. Staff N stated Resident #3 did not voice any concerns to her at that time. Staff N stated Resident #3 said she wanted her brief changed because there was a rip and told her the brief would still work just fine. Staff N stated she explained to Resident #3 that urine would not get everywhere. Staff N said Resident #3 said she could not wear it because there was a tear. Staff N stated she explained to Resident #3 the tear was not an issue because it was just a little tear. Staff N stated if she asked her to change the brief she would have changed it but she did not ask her to change it. Staff N said Resident #3 just said she could not wear it because it was ripped. Staff N stated she had been upset all day and did not seem anymore upset from the incident. On 4/29/26 at 12:42 PM the Director of Nursing (DON) stated Staff N ripped the brief and Resident #3 stated she wanted a brief change. The DON explained that Staff N said she would not change the brief. The DON stated Staff N should have changed the brief. The DON acknowledge a lack of dignity did occur when Staff N refused to change Resident #3's brief.Review of a policy provided by the facility dated 2/20 titled, Quality of Life - Dignity documented residents are treated with dignity and respect at all times. The facility's culture is one that supports and encourages humanization and individuation of residents, and honors resident choice, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's stay. Some examples of ways in which respect for choices and values are exercised included personal grooming - residents are groomed as they wish to be groomed. Residents are encouraged and assisted to dress in their own clothes.

Based on clinical record review, staff interview, and policy review the facility failed to provide complete and accurately documented electronic health records for 4 of 5 residents (Residents #2, #5,#6, and #7) reviewed. The facility reported a census of 61 residents.Findings include: 1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS further revealed diagnoses of heart failure, peripheral vascular disease, renal insufficiency, diabetes mellitus, and chronic obstructive pulmonary disease.Review of Resident #2's Electronic Healthcare Record (EHR) page titled, Clinical Immunizations revealed Resident #2 refused the Covid-19 vaccine. Review of Resident #2's EHR page titled, Progress Notes revealed no entry of Resident #2 refusing the Covid-19 vaccine. 2. Review of Resident #5's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed diagnoses of coronary artery disease, renal insufficiency, diabetes mellitus, and a personal history of Covid-19. Review of Resident #5's Electronic Healthcare Record (EHR) page titled, Clinical Immunizations revealed Resident #5 refused the Covid-19 vaccine, influenza vaccine, and the pneumococcal vaccine. Review of Resident #5's EHR page titled, Progress Notes revealed no entry of Resident #5 refusing the Covid-19 vaccine, influenza vaccine, or the pneumococcal vaccine. 3. Review of Resident #6's MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognition. The MDS further revealed diagnoses of heart failure, peripheral vascular disease, diabetes mellitus, and chronic obstructive pulmonary disease. Review of Resident #6's Electronic Healthcare Record (EHR) page titled, Clinical Immunizations revealed Resident #6 refused the Covid-19 vaccine. Review of Resident #6's EHR page titled, Progress Notes revealed no entry of Resident #6 refusing the Covid-19 vaccine. 4. Review of Resident #7's MDS dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. The MDS further revealed diagnoses of chronic obstructive pulmonary disease, and respiratory failure. Review of Resident #7's Electronic Healthcare Record (EHR) page titled, Clinical Immunizations revealed Resident #7 refused the Covid-19 vaccine. Review of Resident #7's EHR page titled, Progress Notes revealed no entry of Resident #6 refusing the Covid-19 vaccine. Interview on 10/06/25 at 1:05 PM with the Director of Nursing (DON) revealed she didn't have declination forms signed if residents refused vaccines. The DON further revealed the facility does have acceptance forms. The DON then revealed that she gives the vaccinations at the facility, and she only marks if it is accepted by the resident. The DON revealed that if the resident had a lower BIMS score or had a medical Power of Attorney (POA) then the facility would contact them if they would want their loved ones to have the vaccine or not. The DON again revealed that the facility would only mark on the form if they accepted the vaccine, or if a POA refused that it would be documented in the progress notes. Interview on 10/7/25 at 8:15 AM with the Administrator revealed that her expectation would be for when a vaccine is refused for it to be charted in the medical records with a declination form signed. Review of a facility provided policy titled, Vaccination of Residents with a revision date of October 2019 revealed:a. If vaccines are refused, the refusal shall be documented in the resident's medical record.

Based on review of the planned menu, observations, staff interviews and facility policy review the facility staff failed to follow the planned menu for residents. The facility identified a census of 61 residents. Findings include: Review of the menu for Week 5 Day 3 identified the following items as part of the planned menu for the lunch meal on 5/13/25: Turkey Tetrazzini Buttered Peas Bread and margarine Fruited Gelatin Milk Observation on 5/13/25 at 10:47 a.m., of the puree process no bread and margarine was pureed for the lunch meal. Observation on 5/13/25 at 12:48 p.m., of lunch meal service revealed the lunch meal served consisted of: Turkey Tetrazzini Buttered Peas Fruited Gelatin Observation of lunch service was completed with the main dining room. No bread and margarine was served with the lunch meal, noted resident menus to have circled bread and margarine as meal choice. Review of the facility provided policy titled Accuracy and Quality of Tray Line Service dated 2021 revealed the following: a. tray line and or meal service positions for breakfast, lunch and dinner will be planned and determined according to the menu. b. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu. Interview on 5/13/25 at 12:51 p.m., with the Dietary Manager and the Dietician revealed if the menu had bread and margarine and the resident picked the item it should have been served. The Dietician further revealed residents on a pureed diet should have been served the bread and margarine as well.

Based on direct observation, resident interviews, staff interviews, and document review the facility failed to provide and document restorative cares for 4 of 4 residents reviewed (Residents #4, #37, #41 and #42). The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of repeated falls, muscle wasting, unsteadiness on feet and need for assistance with personal care. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. In an interview on 5/14/25 at 2:08 PM, Resident #4 reported he rides the therapy bike about once a week. When asked if he received other restorative care the resident said, no I ride the bike once a week. The resident denied he received restorative care for transfers. The Care Plan for Resident #4 showed ADL self-care performance deficit related weakness, balance deficit, and activity intolerance following hospitalization . A restorative program and well groups to maintain strength and balance initiated on 11/24/24. The May 2025 Restorative Care Flow Record for Resident #4 showed the goal to maintain ADLs transfer gait abilities. The record showed restorative care occurred two times in 15 days. The May 2025 Restorative Nursing Program Weekly Review for Resident #4 showed no restorative care occurred in week 1. 2. The MDS assessment dated [DATE] for Resident #37 documented diagnoses of muscle wasting, muscle weakness, and stroke. The MDS showed the BIMS score of 14, which indicated no cognitive impairment. In an interview on 5/14/25 at 10:01 AM, Resident #37 stated, They don't have time to do all the restorative therapy. I get therapy once a week, sometimes twice a week. Resident #37 did not believe she lost function but is afraid that she might if restorative therapy is not performed regularly. The Care Plan for Resident #37 showed an ADL self-care performance deficit and limited physical mobility related to weakness, balance deficit, and activity intolerance following hospitalization . The resident participates with restorative program initiated on 1/27/22. The May 2025 Restorative Care Flow Record for Resident #37 showed the goal to maintain current ADLs transfer gait abilities. The record showed restorative care occurred two times in 15 days. The May 2025 Restorative Nursing Program Weekly Review for Resident #37 showed no restorative care occurred in week 1. 3.The MDS assessment dated [DATE] for Resident #41 documented diagnoses of muscle wasting, muscle weakness, and unsteadiness on feet. The MDS showed the BIMS score of 15, which indicated no cognitive impairment. In an interview on 5/14/25 at 10:08 AM, when asked if Resident #41 received restorative care, help with range of motion and with walking the resident stated, no. When asked how often she received help with restorative care the resident replied, I don't. When asked if she understood what restorative care meant the resident stated, exercises, I don't get help with exercises. The Care Plan for Resident #41 showed required occasional ADL and Mobility assist related Sequela effects from stroke. Resident #41 will be encouraged to continue to be as independent as possible with ADLs and as she is able to tolerate and remain safe, she will be encouraged to participate in wellness groups and restorative programs initiated on 7/8/24. The May 2025 Restorative Care Flow Record for Resident #41 showed the goal to maintain current transfers. The record showed restorative care occurred two times in 15 days. The May 2025 Restorative Nursing Program Weekly Review for Resident #41 showed no restorative care occurred in week 1. 4. The MDS assessment dated [DATE] for Resident #42 documented diagnoses of Chronic Obstructive Pulmonary Disease (COPD), general weakness, repeated falls and need for assistance with personal cares. The MDS showed the BIMS score of 14, which indicated no cognitive impairment. In an interview on 5/12/25 at 1:06 PM, Resident #42 reported he received restorative care a couple of times since last month. Resident #42's Family Member stated, he doesn't get help. They need to make sure he doesn't lose anymore. The program here doesn't exist. We came here because it was five stars but they're not doing what they're supposed to. The Care Plan for Resident #42 showed a risk for falls related to balance deficit, weakness, and history of falls. A restorative program and well groups to maintain strength and balance initiated on 11/3/24. The May 2025 Restorative Care Flow Record for Resident #42 showed the goal to maintain current ambulation functional transfers and with Activities of Daily Living (ADL). The record showed no restorative occurred in May. The May 2025 Restorative Nursing Program Weekly Review for Resident #42 showed no review occurred. The Restorative Nursing Services policy last dated July 2017 identified: Policy Statement : Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation: Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g, physical, occupational or speech therapies). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. The resident or representative will be included in determining goals and the plan of care. Restorative goals may include, but are not limited to supporting and assisting the resident in: Adjusting or adapting to changing abilities;Developing, maintaining or strengthening his/her physiological and psychological resources; Maintaining his/her dignity, independence and self-esteem; and Participating in the development and implementation of his/her plan of care. In an interview on 5/14/25 at 10:05 AM the Restorative Aide reported she often gets reassigned to resident care. The Restorative Aide stated, I can't do restorative care, I don't have time. I have to take care of the residents. In an interview on 5/15/25 at 9:27 AM, the Director of Nursing (DON) stated unfortunately restorative care doesn't always get done. We had staff quit and we had to pull the restorative aide to fill in on the floor.

Based on record review, interview, and facility policy the facility failed to have the Medical Director at quarterly meetings for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 61. Findings include: Review of the facility document titled Quality Assurance Performance and Improvement Meeting Minutes: a. Document dated 11/13/24 lacked the signature of the Medical Director Review of the facility provided policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership dated March 2020 revealed the following individuals serve on the committee, Medical Director. The committee meets at least quarterly or more often as necessary. Interview on 5/15/25 at 09:40 a.m., with the Director of Nursing revealed the Medical Director should be at the quarterly meetings.

Based on observation, interviews and record review the facility failed to ensure that staff used appropriate hand hygiene during resident cares for 1 of 3 residents reviewed, (Resident #3). The facility reported a census of 61 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #3 was not able to participate with a Brief Interview for Mental Status (BIMS) due to severe cognitive deficits. She was total dependent on staff for dressing, toileting and transfers. The Care Plan last updated on 5/9/25, showed that Resident #3 had self-care performance deficit with limited physical mobility. The resident had cognitive deficits, weakness and activity intolerance. Resident #3 had frequent incontinence, she was to be offered toileting before and after meals and with rounds at night. Her diagnoses include post-polio syndrome, intracerebral hemorrhage, type 2 diabetes, and chronic kidney disease. On 5/12/25 at 1:40 PM Staff E, Certified Nurse Aide (CNA) and Staff H, CNA transferred Resident #3 from the wheel chair to the bed, with the use of the full-body mechanical lift. The sling for the lift was already under the resident. They hooked her up to the lift and as they raised her into the air, urine spilled through her clothing and pooled in the seat of the wheel chair. As she was transferred to the bed, urine dribbled across the floor. Staff E and Staff H removed the soiled clothing with gloved hands, then braced the resident and rolled her onto her side with the same gloves. After completing incontinence cares, Staff F left the resident's room without washing her hands. On 5/13/25 at 1:24, Staff G, CNA and Staff F, CNA provided incontinence cares for Resident #3. Staff G changed her gloves several times but failed to use hand sanitizer between changes. Both of the staff members left the room without washing their hands. On 5/15/25 at 9:12 AM, the Director of Nursing (DON) said that they provide education and random audits to monitor appropriate hand hygiene. Staff were taught to change gloves after touching soiled areas and to wash their hands before leaving the residents rooms. A facility policy undated titled; Personal Protective Equipment-Gloves shoed that all employees must wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes and or non-intact skin. Gloves should be used only once and discarded. An undated facility policy titled: Handwashing/Hand Hygiene, showed that all personnel would follow handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel residents and visitors.

Based on observation, clinical record review, staff and resident interviews, the facility failed to train staff to maintain properly maintain CPAP settings for resident usage for 1 of 2 residents reviewed (Resident #42). The facility reported a census of 61 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 documented diagnoses of Chronic Obstructive Pulmonary Disease (COPD), insomnia and renal insufficiency.The MDS indicated Resident #42 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Observation on 5/12/25 at 1:12 PM revealed a CPAP on Resident #42's bedside table. Resident #8 reported he used the CPAP during sleep. The Family Member reported staff set a pillow on the CPAP and they weren't certain if settings were inadvertently changed. The Family Member reported she took the CPAP to the home supplier to make certain the settings were correct. The Family Member stated, I don't think it should be my job to take the machine downtown to make sure it's set right. Someone here should be able to know the settings and check just in case something goes wrong. The Family Member stated, No one helps him with the CPAP. The Receptionist comes to help with the CPAP machine because no one knows how to operate it. The Family Member stated, the Receptionist had to come in the room to help them two different times because no one knew how to run the CPAP. No nurse knew how to run it, there's no respiratory therapist, no nothing. In an interview on 5/14/25 at 9:47 AM, the Receptionist reported she assisted Resident #42 with the CPAP two different times. The Receptionist stated, I did it because no one else knew how. No one knew how to operate it. I was the only one. I have a CPAP, so I knew what to do then the DON found out and told me that I couldn't do that anymore. In interview on 5/15/25 at 9:27 AM, the Director of Nursing (DON) reported she knew the Receptionist assisted Resident #42 because the facility lacked staff trained in CPAPs. The DON reported only a respiratory therapist should be monitoring the CPAP settings as needed. When asked if the facility had a respiratory therapist the staff could reach if needed, the DON replied no it's something we need to work on.

Based on observation, interview and record review the facility failed to update the Care Plan for 1 of 17 residents reviewed. Resident #36 was admitted to Hospice on 4/16/25 and staff failed to include a focus area for the special service. The facility reported a census of 61 residents. Findings include: According to the Minimum Data Set assessment dated [DATE], Resident #36 did not have a Brief Interview for Mental Status (BIMS) assessment completed due to severe cognitive deficits. She was total dependent for dressing, hygiene, transfers and toileting. Her diagnoses included; diabetes mellitus, Alzheimer's disease, cerebrovascular accident (CVA) hemiplegia or hemiparesis, and oral dysphagia, The Care Plan updated on 4/8/25 showed that Resident #36 was on oxygen therapy, she was not able to ambulate or propel a wheel chair. The resident required 2 staff with mechanical lift for transfers and required assistance with all decision making. The Care Plan lacked a focus area for Hospice. On 5/12/25 at 11:11 AM, Resident #36 was in a high-backed wheel chair and her husband sat in a chair next to her. He said that the resident had experienced several CVA episodes and that Hospice services had recently started. The resident's chart included a Physician Fax, dated 4/17/25 that Hospice had accepted Resident #36 as of 4/16/25. On 5/15/25 at 9:12 AM, The Director of Nursing (DON) said that she would expect an addition of Hospice would be on the Care Plan as soon as a resident was admitted to Hospice. A facility policy titled: Care Plans, Comprehensive Person-Centered indicated that a comprehensive, person centered care plan would include measurable objective and timetable to meet the resident physical, psychosocial and functional needs. The care plan would describe services that were to be furnished to attain and maintain the residents highest practicable physical mental and psychosocial well-being.

Based on observation, interview and record review the facility failed to provide adequate assistance with Activities of Daily Living (ADL) for 2 of 3 residents reviewed (Resident #3 and #19.) Resident #3 required regular toileting and repositioning, she was found to be sitting in a urine saturated brief, and in her wheel chair with her legs dangling without support. Resident #19's urinary catheter was hanging on the bedrail above the bladder. The facility reported a census of 61 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #3 was not able to participate with a Brief Interview for Mental Status (BIMS) due to severe cognitive deficits. She was total dependent on staff for dressing, toileting and transfers. The Care Plan last updated on 5/9/25, showed that Resident #3 had self-care performance deficit with limited physical mobility. The resident had cognitive deficits, weakness and activity intolerance. She was not able to ambulate and dependent on 2-staff assistance with a mechanical lift for transfers. Staff were directed to use a padded foot rest under her lower legs while in the wheel chair. She was at risk for falls and staff were to anticipate and meet her needs. Resident #3 had frequent incontinence, she was to be offered toileting before and after meals and with rounds at night. Her diagnoses include post-polio syndrome, intracerebral hemorrhage, type 2 diabetes, and chronic kidney disease. On 5/12/25 at 1:40 PM Staff E, Certified Nurse Aide (CNA) and Staff H, CNA transferred Resident #3 from the wheel chair to the bed, with the use of the full-body mechanical lift. The sling for the lift was already under the resident. They hooked her up to the lift and as they raised her into the air, urine spilled through her clothing and pooled in the seat of the wheel chair. As she was transferred to the bed, urine dribbled across the floor. When asked the last time that the resident had been toileted, Staff H said she was changed before lunch. On 5/13/25 at 6:24 AM, Resident #3 was in her wheel chair near the nurse's station in front of the television with her head hanging, and sleeping. Her feet did not reach the foot pedals and dangled. There was no padded foot rest under her legs or feet. On 5/14/25 at 6:15 AM, Resident #3 was in the wheel chair near the nurse's station sleeping. She was slouched down in the seat, her feet dangled, and did not reach the pedals. At 7:30 AM, the resident was in the same position. On 5/14/25 at 11:39 AM, Staff M said that the overnight CNA's were directed to get Resident #3 up and dressed at 5:30 every morning. She said that at times, they need to wake her up, but she did not know why they had to get the resident up so early. On 5/14/25 at 12:51 PM, Staff J CNA, said that he worked the overnight shift and sometimes the aides would wake up Resident #3 before 6:00 AM and transfer her to the wheelchair. Once in the wheel chair, she would often fall asleep. On 5/14/25 at 1:12 PM, Staff N, Licensed Practical Nurse (LPN) said she worked overnights that Resident #3 was up by 6:00 AM because she was on the get up list. Staff N said that the resident would sometimes holler out early in the morning. 2) According to the MDS dated [DATE], Resident #19 had a BIMS score of 12 (moderate cognitive deficit.) He was totally dependent on staff for toileting hygiene and dressing, and required substantial assistance with transfers. The resident was occasionally incontinent of bowel, and had an indwelling urinary catheter. His diagnoses included; benign prostatic hyperplasia, renal insufficiency, pneumonia and septicemia. The Care Plan updated on 5/6/24, showed that Resident #19 had an indwelling Foley Catheter, staff were to provide catheter care every shift and as needed, and to monitor for signs and symptoms of urinary tract infections. The following was included in the Nursing Progress Notes: a. On 4/5/25 at 10:39 AM, the Foley catheter was plugged, unable to flush, drains cloudy straw yellow urine with sediment. b. On 4/6/25 at 4:16 PM, doctors order for a urinary analysis with culture due to cloudy purulent urine with foul odor. c. On 4/7/25 at 9:08 PM, Resident #19 was started on an antibiotic for urinary tract infection. On 5/14/25 at 6:15 AM, Resident #19 was laying on his left side in bed and the catheter bag was hanging on the bed rail, near his head, and above the bladder. At 7:20 AM, Staff K, LPN, acknowledged that the catheter bag should be hung at level below the bladder. On 5/15/25 at 9:12 AM, the Director of Nursing (DON) said that staff were directed to check and change Resident #3 before and after meals. She said that with the amount of urine described that spilled out of the brief, it wouldn't seem that she had gone that much longer between changes on that day. The DON said that Resident #3 was on a get up list because the resident had been hollering out at 5:30 AM, so staff were getting her up at that time. The DON agreed that if the resident's feet were dangling without support, that was not good positioning, and she should have the support under her legs. The DON said that a catheter bag should not be hanging on the bedrail and should be below the bladder. An undated facility policy titled: Incontinence Care and Toileting showed that residents that are incontinent should be checked and changed every 2 hours, and as needed for incontinence management. An article titled: Indwelling Urinary Catheter Insertion and Maintenance; Retrieved on 5/15/25 at 8:19 AM from https://www.cdc.gov/infection-control/media/pdfs/Strive-CAUTI104- 508.pdf showed that in order to maintain unobstructed urine flow, keep the bag below the level of bladder when a drainage bag was raised above the level of bladder, contaminated urine from the drainage bag or tubing may reflux into the bladder or organisms may be introduced when there are breaks in the closed drainage system.

Based on observation, interview and record review the facility failed to adequately supervise vulnerable residents to prevent injury for 1 of 3 residents reviewed (Resident #3). Resident #3 was observed to have a bruise on her right cheek that spread up under her eye. Staff hypothesized about the cause, but were unable to fully explain the injury. The facility reported a census of 61 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #3 was not able to participate with a Brief Interview for Mental Status (BIMS) due to severe cognitive deficits. She was total dependant on staff for dressing, toileting and transfers. The Care Plan last updated on 5/9/25, showed that Resident #3 had self-care performance deficit with limited physical mobility. The resident had cognitive deficits, weakness and activity intolerance. She was not able to ambulate and dependent on 2-staff assistance with a mechanical lift for transfers. Staff were directed to use a padded foot rest under her lower legs while in the wheel chair. She was at risk for falls and staff were to anticipate and meet her needs. Resident #3 had frequent incontinence, she was to be offered toileting before and after meals and with rounds at night. Her diagnoses include post-polio syndrome, intracerebral hemorrhage, type 2 diabetes, and chronic kidney disease. In an observation on 5/12/25 at 1:40 PM, Staff E CNA and Staff H CMA transferred Resident #3 from the wheel chair to bed with the use of a mechanical lift. The resident did not hold her head up very well and made repetitive tongue movements and in-auditable, sounds that increased in volume and number as the staff moved her to the bed with the lift. Resident #3 had a large bruise under her right eye, with yellow area around the outside and purple in middle. An incident report titled: Injury of Unknown Cause, dated 5/10/25 at 6:00 AM, showed that Resident #3 was sitting in her wheel chair in the dining room area when Staff C, Licensed Practical Nurse, (LPN) noticed the bruise on her right cheek. The immediate action taken, was to educate staff on the proper use of the Hoyer (mechanical lift.) According to the Pressure Ulcer/Non-Pressure Ulcer Healing Record Dated 5/10/25, the right cheek bruise measured 3 centimeters (cm) x 2 cm. It was light blue with a red center. On 5/13/25 at 1:47 PM, Staff C, said that on the morning of 5/10/25 she worked at 6:00 AM and Resident #3 was in her wheel chair out in the dining room area. She noticed bruising under her eye seemed faint with red in center. She talked to the overnight nurse and CNA who had not yet left and asked them what happened, they both said that they didn't have any knowledge of any accidents and this was the first that they saw it. Staff C said that the resident had a pair of glasses, but she didn't wear them very often. The glasses were bent and didn't fit on her face very well. Resident #3 was not able to tell them how she got the bruise. On 5/13/25 at 11:50 AM a family member said that she got a call about the bruise was told that they didn't know how it happened. They thought the Hoyer arm swung back and hit her face. The family member said that Resident #3 spoke very few words but she would be able to say if anyone hit her or intentionally hurt her. On 5/14/25 at 10:20 AM, the Director of Nurse (DON) said that she had just started an investigation on the bruising on the resident. She said that the most likely explanation was that the Hoyer arm hit her and said that the resident bruised so easy that it could have tapped her on the face and staff would maybe not even notice. On 5/15/25 at 9:12 AM, the DON said that after further investigation she and the staff believe that Resident #3 may have fallen asleep with her glasses on and that pressed into her check, could have caused bruise. According to an undated facility policy titled: Abuse, Neglect and/or Misappropriation of Resident Funds or Property Exploitation Prohibition, injuries of unknow source, would be evaluated and staff would make necessary changes in resident care plan to protect against the occurrence of similar injuries.

Based on observations, record review, staff and resident interviews, and policy reviews, the facility failed to provide staff with current continuous positive airway pressure (CPAP) machine settings, and failed to monitor and maintain CPAP mask and tubing needs for 2 of 2 residents reviewed (Resident #8 and #42). The facility reported a census of 61. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 documented diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD) and renal insufficiency.The MDS indicated Resident #8 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Observation on 5/12/25 at 1:48 PM revealed a CPAP on Resident #8's bedside table. Resident #8 reported she used the CPAP during sleep. Resident #8 reported she used the same CPAP mask and tubing since admission in June 2024. Resident #8 stated, you can tell the tubing and mask are worn. Observation showed the tubing to be misshaped and the mask to be darkened around the nose pillow and headgear. Resident #8 reported no knowledge of the CPAP settings. The Clinical Physician Orders for Resident #8 showed 7/23/24 a CPAP ordered to be used during hours of sleep. No CPAP settings present. The Care Plan for Resident #8 showed admission occurred on 6/20/24 and showed a diagnosis of sleep apnea. The Care Plan indicated Resident #8 used a CPAP during hours of sleep, settings per provider and to assist in cleaning and maintaining the CPAP. No CPAP settings present. Review of Resident #8's chart on 5/13/25 at 10:43 AM failed to show CPAP settings or documentation of the CPAP mask and tubing change. In an interview on 5/14/24 at 12:04 PM, the Intake Coordinator at the CPAP home equipment supplier reported no supplies ordered since 2019. 2. The MDS assessment dated [DATE] for Resident #42 documented diagnoses of Chronic Obstructive Pulmonary Disease (COPD), insomnia and renal insufficiency.The MDS indicated Resident #42 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Observation on 5/12/25 at 1:12 PM revealed a CPAP on Resident #42's bedside table. Resident #8 reported he used the CPAP during sleep. Resident #42 and a present Family Member reported Resident #42 used the same CPAP mask and tubing since over a year ago. The Family Member reported staff set a pillow on the CPAP and they weren't certain if settings were inadvertently changed. The Family Member reported she took the CPAP to the home supplier to make certain the settings were correct. The Family Member stated, I don't think it should be my job to take the machine downtown to make sure it's set right. Someone here should be able to know the settings and check just in case something goes wrong. Observation showed the tubing to be misshaped and the mask to be darkened around the nose pillow and headgear. The Progress Note dated 5/8/2025 at 3:21 PM for Resident #42 indicated the following documentation: CPAP machine and respiratory therapy, reminded the family that we do not have a respiratory therapist on staff as she feels we should. I asked her to inquire with the company she purchased the machine from if she has questions regarding proper functioning. I will reach out to pulmonology to clarify settings for CPAP. The Clinical Physician Orders for Resident #42 showed 10/24/24 a CPAP ordered to be used at bed time for sleep apnea. No CPAP settings present. The Care Plan for Resident #42 showed this admission occurred on 10/24/24. The Care Plan indicated Resident #42 used a CPAP during hours of sleep, settings per provider and to assist in cleaning and maintaining the CPAP. No CPAP settings present. Review of Resident #42's chart on 5/13/25 at 10:43 AM failed to show CPAP settings or documentation of the CPAP mask and tubing change. In an interview on 5/14/24 at 11:41 AM, the Branch Coordinator at the CPAP home equipment for Resident #42's supplier reported no supplies ordered since 9/7/23. The Branch Coordinator reported the supplier had a replacement schedule for CPAP machines. In an interview on 5/15/25 at 9:27 AM, the Director of Nursing (DON) reported the facility is responsible for maintaining the CPAP machines. The DON reported the CPAP settings should be available for staff if needed. The DON reported she has never thought about CPAP supplies. The DON stated, Now that I think about it, we are responsible for the CPAPs, so it makes sense we look into the supplies. I'm not 100% sure how insurance works on that. I have some research to do. The CPAP Supplier Replacement Schedule showed the following: Frame used with CPAP device (if gotten separately from kit), maximum replacement allowance for insurance, 1 per 3 months. Headgear, used with CPAP device (if gotten separately from kit), maximum replacement allowance for insurance, 1 per 6 months. Mask Kit (which would include the Headgear and frame), maximum replacement allowance for insurance, 1 per 6 months. Replacement cushion for full face mask, maximum replacement allowance, for insurance 1 per 1 month. Replacement nasal cushion for nasal mask, maximum replacement allowance, for insurance 2 per 1 month. Replacement pillows for nasal pillow mask, maximum replacement allowance for insurance, 2 per 1 month. Chin strap, used with CPAP device, maximum replacement allowance for insurance, 1 per 6 months. Tubing, used with CPAP device, maximum replacement allowance for insurance, 1 per 3 months. Filter, disposable, used with CPAP device (white filters), maximum replacement allowance for insurance, 2 per 1 month. Water Chamber for humidifier used with CPAP device, maximum replacement allowance for insurance, 1 per 6 months. Tubing with integrated Heating Element for use with CPAP device, maximum replacement allowance for insurance, 1 per 3 months. *Replacement schedules are subject to change based upon physician orders, your medical condition, and the discretion of your insurance company* The Continuous Positive Airway policy last updated July 2019 indicated: DESCRIPTION: 1. CPAP (Continuous Positive Airway Pressure) - Provides continuous positive airway pressure (CPAP) to airways to spontaneously breathing Residents. Delivered via circuit to mask nasal prongs or trach. 2. BIP AP (Bi Level Positive Airway Pressure) - Provides CPAP but allows for different pressures on inhalation and expiration. Also allows for a back up respiratory rate to be set. PURPOSE: 1. To augment Resident breathing 2. To treat Resident with sleep disorders. 3. To correct arterial hypoxema. 4. To avoid tracheostomy and/or mechanical ventilation. 5. To decrease atelectasis. 6. To increase compliance. EQUIPMENT NEEDED: 1. CAP/BIPAP unit 2. CPAP mask kit, nasal prong kit or trach adapter 3. Whisper Swivel 4. CPAP/BIPAP circuit or 6 corrugated tubing (CPAP/BIPAP) and pressure adapter, oxygen tubing 5. Head strap (for mask and nasal prongs only) 6. Bacteria Filter 7. Pressure manometer or NIF meter (with tubing/pressure adapter) 8. Optional a. [NAME] Strap b. Humidifier and 18 corrugated tubing c. Oxygen adapter and tubing d. Apnea monitor and supplier e. Pulse oximeter nose wheel f. External Pressure Alarm, tubing and adapter POLICY: 1. CAP/BIPAP MUST NOT be used for life support. It is not a ventilator. 2. Must be ordered by the physician. 3. All orders must include the following: a. Type of unit (CPAP/BiPAP) b. Pressure setting(s) c. Oxygen order (if applicable) d. Delivery device and size (mask, nasal prongs, trach) e. Frequency of therapy (continuous, at HS, etc.) f. Need for humidifier 4. BIPAP users must be monitored at least every 4 hours for breathing patterns, color and respiratory status. 5. Circuits are to be cleaned/changed weekly. 6. Change filters every thirty (30) days and PRN. Clean non-disposable filters weekly. PROCEDURE: The respiratory therapist/nurse shall follow the steps outlined below when setting up a CAP/BiPAP unit: 1. Gather equipment. 2. If needed, fill the humidifier to full line with sterile water and attach to the unit. Connect one end of 18 corrugated tubing to the outlet port of the unit and the other end to the inlet port of the humidifier. 3. Connect bacterial filter to outlet port of unit. 4. Assemble circuit (if not using pre-made circuit): a. Connect whisper swivel to mask, nasal prong holder or trach adapter. b. Connect the pressure adapter to the other end of the whisper swivel. Connect oxygen tubing to the adapter. c. Connect 6 corrugated tubing to the other end of the whisper swivel or pressure adapter. 5. If oxygen is ordered: a. Place the oxygen adapter on the end of the bacteria filter, connect one end of the oxygen tubing to the adapter, and the other end to the oxygen source. b. Turn oxygen on to prescribed LPM. If a specific FiO2 was ordered, place the oxygen analyzer inline and adjust LPM until FiO2 is met. 6. Connect the end of the circuit to the outlet port of the unit or humidifier. 7. Connect pressure manometer. 8. Set pressure(s), ramp time and mode (spontaneous, resp. rate) per physicians' orders. 9. Plug unit in and turn on. 10. Make a tight seal on mask: prongs or trach adapter. Assure there are no leaks in the circuit. Measure Resident's nose with rose wheel. 11. Check pressure manometer to verify pressure settings. Cycle BiPAP unit by alternately occluding then opening circuit outlet 12. Adjust pressures as needed. 13. Assure that all panel doors on wit are closed and locked. 14. Connect delivery device to Resident. Make sure there is a tight seal. 15. Assure that pressure level(s) are maintained. 16. When using BiPAP place Pulse Ox on Resident and apnea monitor if applicable. 17. If using BIPAP on a trached Resident, place external alarm in-line following. 18. Assure the Resident can tolerate use of equipment and is having no difficulty in breathing CLINICAL CONSIDERATION: 1. Indications: a. Residents who exhibit unacceptable or worsening hypo-ventilation as reflected by elevation or rising PaCO2. b. Residents with chronic ventilatory muscle dysfunction. c. Residents with unacceptable hypotemia despite administration of higher FiO2's (P50%). d. Residents with sleep disorders. 2. Contradictions: a. Unastable facial fracture b. Extensive facial lacerations. c. Pre-existing pneumothorax or pneumomediastinum. d. Pre-existing bullous disease. e. Allergies or hypersensitivity to mask f. Frequent emesis. g. Laryngeal trauma. h. Recent gastric surgery 3. Side effects (typically only found with higher pressures): a. Gastric Distention. b. Decreased cardiac and urinary output. c. Carbon Dioxide retention. d. Skin abrasions or breakdown. e. Resident discomfort facial and ear discomfort f. Acute sinusitis or middle ear infection. g. Hypotension due to positive pressure breathing. h. Inability to breathe during disconnect or loss of flow. 4. Precautions: a. Advise Resident to immediately report any chest discomfort, shortness of breath or headache. b. When using a mask, advise Resident not to eat 2-3 hours prior to using the unit. c. Whisper swivel must not be occluded at any time. This is the only exhalation port. d. IPAP and EPAP settings should be re-evaluated when there is a change in Resident physiological condition. 5. Documentation: a. Residents on a CPAP or BiPAP should be checked for breathing patterns, color and respiratory status every 4 hours and this assessment should be documented in the nursing notes every shift while on Medicare part A.

Based on observation, record review, document review, and staff interview the facility failed to provide appropriate infection prevention practices by not completing appropriate hand hygiene, failed to develop policies related to COVID-19 vaccinations, and not following guidelines for enhanced barrier precautions for 63 of 63 residents reviewed. The facility reported a census of 63 residents. Finding include: 1. The Minimum Data Set (MDS) for Resident #24, dated 3/18/2024 documented a Brief Interview for Mental Status of 13 indicating no cognitive impairment. The MDS documented a feeding tube present while a resident. On 5/21/24 at 7:52 AM an observation of Staff E Licensed Practical Nurse (LPN) revealed no hand hygiene prior to entering Resident #24 ' s room. Staff E entered Resident #24 ' s bathroom, obtained gloves, and applied gloves. Staff E pushed via 60 mL syringe 10 mL of tap water to auscultate for enteral tube placement. Staff E then pushed medications with a piston syringe. Staff E did not allow medications to flow by gravity. Staff E then removed gloves and applied new gloves without hand hygiene. Staff E poured enteral formula into the hanging bag. Staff E connected the enteral feeding bag Resident #24 ' s enteral feeding tube. Staff E removed gloves and rinsed the piston syringe. Staff E returned to the medication cart and completed hand hygiene. No enhanced barrier precautions in place during care by Staff E. No gown donned during resident care. Review of Resident #24 ' s Physician Orders revealed an order for gastrostomy tube to be changed every 6 to 9 months. Review of undated policy titled, Hand Hygiene documented situations that require hand hygiene include but are not limited to before and after direct resident contact, before and after entering isolation precautions, before and after assisting residents with personal care, before and after applying gloves, before and after coming in contact with residents intact skin, and after removing gloves, 2. The MDS dated [DATE] documented Resident #44 had a BIMS of 2 indicating severe cognitive impairment. The MDS documented Resident #44 was staff dependent during personal hygiene. On 5/22/24 at 8:06 AM an observation of catheter cares and peri cares completed on Resident #44 by Staff J, Staff K, and Staff L revealed hand hygiene was completed by all staff. Gloves applied by all staff. Staff J completed catheter cares to Resident #44 ' s suprapubic stoma site cleansing from stoma down catheter tubing. Staff J completed peri care from labia out to the groin and abdomen. Staff K helped with positioning Resident #44 from side to side during care. Staff J, Staff K, and Staff L removed gloves, hand hygiene completed by all of the staff, and new gloves applied. Resident #44 was turned to the right side buttocks cleansed from cleft to outward to hip on the left side. Resident #44 was turned to the left side and cleansed from the cleft outward to hip. Staff J, Staff K, and Staff L removed gloves, completed hand hygiene, and applied gloves. Barrier cream and brief applied to Resident #44. Staff J, Staff K, and Staff L removed gloves and hand hygiene completed. Trash and laundry removed from the room. No enhanced barrier precautions in place during care by Staff J, Staff K, or Staff L. No gowns donned during resident care. Review of Resident #44 ' s Physician Orders revealed size 22 french suprapubic catheter to be changed every 4 weeks and as needed. 44474 3. The MDS assessment dated [DATE] for Resident #21 documented Resident #21 had an indwelling catheter. Review of Resident #21 ' s Care Plan with revision date of 5/6/24 revealed Resident #21 had an indwelling catheter. Observation on 5/20/24 at 11:05 a.m., of Resident #21 indwelling catheter in the privacy bag hanging under the wheelchair. Observation on 5/21/24 at 2:33 p.m., of Staff D, Certified Nursing Assistant (CNA) assisted Resident #21 with catheter care. Staff D did not wear any Enhanced Barrier Precautions (EBP) during catheter care. Interview on 5/21/24 at 2:40 p.m., with Staff B, Licensed Practical Nurse (LPN) revealed there is no one in the facility on EBP in the facility at this time. Staff B revealed the facility would list it in the medication administration record and would have it listed and it would be passed on. Interview on 5/21/24 at 2:42 p.m., with Staff C, Registered Nurse (RN) revealed there is no one in the facility currently on EBP precautions in the facility at this time. Explained if someone in the facility was on EBP it would be listed in the electronic medical chart in the orders. Stated that they would use it for ulcers. Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 5/21/24 and updated 7/12/22 revealed recent changes included, additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of multidrug-resistant organism (MDRO) colonization among residents in this setting. Expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status). Expanded MDROs for which EBP applies. Clarified that, in the majority of situations, EBP are to be continued for the duration of a resident ' s admission. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. Interview on 5/21/24 at 3:45 p.m., with the Director of Nursing revealed the facility was not currently implementing any EBP at this time but will be implementing it. 4. During the entrance conference on 5/19/24 the facility was requested to provide COVID-19 policy and procedures for the facility. Interview on 5/21/24 at 1:13 p.m., with the Director of Nursing (DON) revealed the facility follows the Centers for Disease Control guidelines for COVID-19 vaccines but does not have that written anywhere.

Based on personnel file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal Background check and dependent adult/child abuse registry check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff N). The facility reported a census of 63 residents. Findings include: Review of untitled payroll information provided by the Human Resource Generalist, Employee N, Certified Nurses Assistant (CNA) date of hire recorded as 2/4/24. The date of birth revealed Staff N to be [AGE] years old at the date of hire. The personnel file for Staff N revealed the file lacked documentation of the Iowa Criminal Background Check. Review of facility provided undated policy titled Employee/Volunteer Background checks instruct high school students age 18 and older who seek employment or who seek employment to volunteer for positions in which they will be working with minor children, are considered adults and will be bound by the same safe environment policies as all other adult volunteers and employees. In an interview on 5/21/24 at 2:13 PM, the Human Resource Generalist revealed per facility policy background checks are not required for staff under [AGE] years of age. In an interview on 5/28/24 at 3:35 PM, the Administrator reported knowledge of federal regulations that all employees are required to have background checks regardless of age. The Administrator is new to the facility and unaware of the facility policy.

Based on Electronic Health Record (EHR) review, observation, policy review and staff interviews the facility failed to prepare food in a form designed to meet individual needs by sending incorrect consistency for modified diet ordered for 4 of 6 residents reviewed (Resident #33, #35, #39, and #44). The facility reported a census of 63 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #33 had a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. The MDS revealed Resident #33 was on a mechanically altered diet. Review of Resident #33 ' s diet order documented a general diet with mechanical soft texture. 2. The MDS dated [DATE] documented Resident #35 had a BIMS of 13 indicating no cognitive impairment. The MDS revealed a diagnosis of dysphagia. Review of Resident #35 ' s diet order documented a low concentrated sweets diet with mechanical soft texture. 3. The MDS dated [DATE] documented Resident #39 was rarely / never understood, indicating severe cognitive impairment. The MDS revealed a diagnosis of dysphagia. Review of Resident #39 ' s diet order documented a general diet with mechanical soft texture. 4. The MDS dated [DATE] documented Resident #44 had a BIMS of 2 indicating severe cognitive impairment. The MDS documented Resident #44 maximal assistance with eating. Review of Resident #44 ' s diet order documented a general diet with mechanical soft texture. On 5/21/24 at 11:50 AM -12:35 PM an observation of lunch service on the 2nd floor revealed Staff F, Dietary Aide / Cleaner served coleslaw to 4 of 6 residents who required mechanical soft diets. Two residents who had orders for a mechanical soft diet wanted the cooked cabbage and stated they could not eat the coleslaw, the cooked cabbage was served to them. Observation revealed none of the residents on mechanical soft diets ate the coleslaw. Review document titled (facility name) SS 2024 (menu) revealed that on 5/21/24 residents on a mechanical soft diet were to be served steamed cabbage. On 5/21/24 at 12:40 PM Staff F stated the menu for 5/21/24 documented that residents on a mechanical soft diet were supposed to have steamed cabbage instead of the coleslaw. Staff F stated he forgot to serve the cabbage to the residents who were on mechanical soft diets. Review of policy titled, Accuracy and Quality of Tray Line Services dated 2021 documented the meal would be checked against the therapeutic diet spreadsheet to assure the food were served as listed on the menu. On 5/21/24 at 1:00 PM Staff G Certified Dietary Manager stated the facility's expectation was that the menu and modified diets of the residents would have been followed. On 5/21/24 at 1:05 PM Staff H Registered Dietitian stated Staff F should have followed the menu for modified diets.

Based on observations, staff and resident interviews and record review the facility failed to identify and report change of condition to the physician in a timely manner and to provide adequate assessment and intervention for 4 of 36 residents reviewed. Residents #55, #001, #113, and #002 experienced a change in condition and the facility failed to ensure that pertinent information was communicated to the physician and that they received a timely response. Facility census was 55 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] assessed Resident #55 with a Brief Interview for Mental Status (BIMS) score of 13 (no cognitive impairment). The MDS showed that the resident required extensive assistance of one staff for transfers and toileting and set up only for eating. A care plan dated [DATE] identified the resident with an indwelling Foley catheter due to [CONDITION(S)] and failed voiding trials. The care plan goals included a goal for the resident to remain free from catheter related trauma and directed staff to monitor and document intake and output per facility policy and report cloudiness, no output, deepening of urine color, foul smelling urine, altered mental status and change in eating patterns. A death certificate dated [DATE] showed that Resident #55 passed away on [DATE] at 4:00 AM. Immediate cause of death was clinical decline, due to or as a consequence of dementia. Observation revealed on [DATE] at 3:53 PM, Resident #55 laid in bed with her urinary catheter hanging on a trash can near the bed. The urine in the bag appeared dark with sediment in the bottom of the bag and throughout the tubing. The resident appeared gaunt and was slow to respond. A review of the record revealed that in the vitals tab of the electronic chart, the resident had a 6.3 pounds (lb.) weight loss from [DATE] at 159.9 lbs. to [DATE] at 149.8. According to a quarterly nutrition assessment dated [DATE] at 10:00 PM, the resident received adequate nutrition with the help of Mighty Shake supplements three times a day. According to the task tab in the electronic chart titled; amount eaten, from [DATE] through [DATE] Resident #55 had opportunity for 72 meals. Of the 72 meals, 41 had no documentation of amount eaten, 16 meals had 0 eaten for a total of 57 meals with 0 or not documented. 3 meals had ,d+[DATE]% eaten, 4 meals had ,d+[DATE]% and 8 meals had ,d+[DATE]% eaten. The electronic chart lacked documentation of the consumption of Mighty Shake supplements. A Medication Administration Record (MAR) in a 15 day period from [DATE]th -[DATE]th revealed the resident's average daily urine output was 1255 cubic centimeters (cc). From [DATE] - 26th the average daily output was 561 cc's. According to the following nursing notes, the resident experienced a decline in health in October: a. [DATE] at 11:17 PM the indwelling catheter patent and draining yellow urine. No concerns noted. b. [DATE] at 5:45 AM resident has a loose moist cough with productive clear phlegm. c. [DATE] at 1:15 PM harsh productive cough with yellow green sputum and lung sounds diminished. Telehealth scheduled for [DATE]. d. [DATE] at 11:25 AM Covid-19 test completed and negative e. [DATE] at 5:00 AM resident is diaphoretic, eyes sunken, urine very concentrated with 100 cc output. Productive cough with thick gray color. Has new orders for [MEDICATION(S)] (antihistamine) and breathing treatment. f. [DATE] 9:55 PM catheter changed due to leaking. g. [DATE] at 6:35 AM catheter changed with 100 cc of cloudy concentrated urine. Coughing episodes when laying on back. h. [DATE] at 3:55 urine is concentrated with foul odor. i. [DATE] at 5:38 PM new order to change catheter from 16 French to 18 French. j. [DATE] at 10:10 AM family concerned about the resident's appetite and facility informed family that the resident took Mighty Shake supplements. k. [DATE] at 2:17 PM resident lethargic with elevated heart rate of 103 beats per minute. l. [DATE] at 9:53 AM call placed to the doctor about recent decline. m. [DATE] at 5:07 fax sent to request a urinalysis (UA) due to scant output and concentrated foul odor and poor fluid intake. n. [DATE] at 9:54 AM lungs diminished o. [DATE] at 1:25 PM call placed to the on-call doctor for a UA and lab came to pick up sample. p. [DATE] at 11:43 PM new order for antibiotic to start on [DATE] q. [DATE] at 5:46 AM the resident passed away at approximately 4:00 AM. On [DATE] at 9:18 AM, Staff F Registered Nurse (RN) and Staff II Licensed Practical Nurse (LPN) sat in the nurse's station on the second floor. When asked how they would know if a resident was to be offered a Mighty Shake supplement, they both responded that it would come up on the MAR along with other medication orders. Staff NN LPN interjected that Resident #55 no longer received Mighty Shake supplements and it was not coming up on the MAR because they do not need a doctor's order for the shakes. When asked who would discontinue the supplement, she said it would probably be the dietician. On [DATE] at 10:08 AM, the dietician stated when the Director of Nursing (DON) started at the facility in March, she decided to change the process for documentation of Mighty Shakes. She said that the DON had the supplement taken off of the MAR and directed the Certified Nursing Assistants (CNA's) to offer them and document on the snack sheet when the residents takes a Mighty Shake. The dietician said that when she did her nutrition assessments she got the information from the snack sheets that were kept on the snack cart. She acknowledged that there were some gaps in the documentation. On [DATE] at 10:20 AM, a review of the snack sheets revealed a spreadsheet in a binder with the names of residents that should be offered magic cup, mighty shake, or other preference for snack. The spreadsheet had no documentation for the month of October. On [DATE] at 5:40 AM, Staff I LPN Staff I stated the snack carts were filled at the beginning of a shift and the CNAs would just ask the residents what they would like for a snack. She was not aware of a list of specific supplements that were to be offered and documented. Staff I said that if a resident was to get a Mighty Shake it would have be entered as an order in the electronic chart and would have come up on the MAR. On [DATE] 9:20 AM Staff EE CNA stated she would offer residents items from the snack cart. When asked how she would know who got a Mighty Shake she said the nurse would tell her because it would have been on their electronic charting. On [DATE] at 5:50 AM Staff T CNA said he would ask the resident what they preferred for snacks and if they are supposed to receive Mighty Shakes. He then mentioned there was a binder with a list of snacks to offer but he was not able to find that binder. On [DATE] at 5:56 AM Staff PP CNA stated there was a binder on the snack cart that would tell them what to offer for snacks. She looked in the refrigerator in the snack room that had 15 Mighty Shake cartons on the shelf, unopened, with resident's names and dates. Resident #55 had three on the shelf with the date on [DATE]. Two other residents had 3 shakes each dated [DATE] and 3 shakes each dated [DATE]. Staff PP did not know the routine for rotating the supplements. On [DATE] at 9:49 the DON said that there had been a breakdown in communication regarding the CNA's offering Mighty Shakes and this happened because of the high turnover in staff. She said that the reason she made the decision to change the process from having the supplement on the MAR to CNA's responsibility was because she felt that it was not being accurately documented when the nurses would just set the Mighty Shakes in front of the resident and walk away. On [DATE] at 1:33 PM the primary physician for Resident #55 said they had been contacted by the facility on the 19th of October for a change in catheter and the resident had been seen on 14th via Telehealth conference. She said the resident experienced some congestion at that time so they gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said a fax was sent on 23rd which was a Friday about scant output and a request for a urinalysis. She said it would have been helpful to have known about the change in condition and she may have ordered labs and/or antibiotic sooner but she could not say if that may or may not have changed the outcome. On [DATE] at 7:47 AM the DON said if a doctor does not respond to a fax from the facility within 24 hours, it was the nurse's responsibility to send another request. If there was no response after the second request, the nurses were expected to follow up with a phone call to the doctor. 2. A MDS dated [DATE] assessed Resident #001 with a BIMS score of 12 (moderate cognitive impairment). The resident required extensive assistance of one staff for dressing and toileting. The MDS showed that the resident required supervision with set up assistance for meals. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for Resident #001 included a focus area of altered nutrition dated [DATE]. The care plan indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received an oral diet and required set up with supervision, and the care plan directed staff to monitor for any swallowing problems. The care plan directed staff to assist at meals, to monitor for any problems and to assess lung sounds after every meal. According to the orders in the electronic chart, the resident received a mechanical soft diet related to dysphagia, oropharyngeal phase. The order was dated [DATE]. According to a nursing note dated [DATE] at 3:24 PM Resident #001 admitted to the hospital for pneumonia and heart failure earlier that day. The death certificate for Resident #001 dated [DATE] identified the cause of death on [DATE] at 3:15 PM as heart failure as a consequence of [CONDITION(S)] disease. On [DATE] at 8:00 AM, Staff K CNA stated three days before Resident #001 passed away he was observed to choking on his food at the dinner table. She said she told the nurse that day, Staff L LPN that he had aspirated. She didn't think that anything had been done and the information was passed onto Staff M LPN. She wasn't sure if either one of the nurses followed up or called the doctor. Nursing notes revealed the following: a. [DATE] at 11:15 PM the resident was able to feed self with set up assist, did not eat much of dinner because he was aspirating. He appeared to be very confused with slow speech. b. [DATE] at 11:15 PM the resident eats meal with peers and lung sounds clear. c. [DATE] at 1:52 PM visit with the doctor no new orders. d. From [DATE] to [DATE], chart lacked information regarding lung assessments. e. [DATE] at 11:31 resident's condition stable. Able to feed self at meals. f. [DATE] at 6:01 PM, CNA reported the resident had difficulty eating. Resident took medications whole without problem. g. [DATE] at 11:01 AM, noticed decline in condition over the last week. Resident has more shaking and sleepier. Fax send to doctor on change in condition. h. [DATE] at 2:34 PM, resident unable to sit on side of the bed. He chewed his pills rather than swallow them. The resident gasped for air. Assessed lungs and heard gurgling. The resident was sent to the emergency room . On [DATE] at 12:05 PM Resident #001's physician stated the outcome would not have changed if he had been notified sooner of the aspirations. He knew that the resident had difficulty swallowing and the resident preferred to continue to eat. 3. A MDS dated [DATE] assessed Resident #113 with a BIMS score of 6 (severe cognitive impairment). The resident was totally dependent and required the assistance of two staff for transfers, dressing and toileting. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated [DATE] identified Resident #113 at risk for altered nutrition and dehydration. The care plan revealed the resident had a urinary catheter and included a plan to monitor for urinary tract infections (UTIs) and observe for change in condition. The care plan directed staff to monitor for [CONDITION(S)] and urine output and report changes to the doctor. According to the census tab in the electronic chart, Resident #113 admitted to the facility on [DATE], admitted to Hospice services on [DATE] and passed away on [DATE]. A death certificate dated [DATE] identified the primary cause of death as [CONDITION(S)] related to [CONDITION(S)]. Nurses notes leading up to the resident's hospitalization on [DATE]: a. [DATE] at 11:09 PM Foley catheter patent and draining clear yellow urine b. [DATE] at 10:56 PM resident coughing with congestion and crackles. Temperature is 99.6 F. Doctor contacted and order received for breathing treatment. c. [DATE] at 2:03 Covid test completed with negative result. d. From [DATE] - [DATE] the chart lacked information regarding lung assessments or concerns with urine consistency or output. e. [DATE] at 12:59 PM Care conference note identified the resident's condition as stable, catheter patent and draining clear yellow urine. f. From ,d+[DATE] - ,d+[DATE] the chart lacked any nursing notes. g. On [DATE] at 1:36 AM, the resident had a temperature of 100.5 with shallow breathing, mouth open and dry. Foley output is concentrated with sediment and strong odor. h. On ,d+[DATE] at 2:04 PM, Covid-19 test administered and found negative. i. [DATE] at 10:53 PM, lower extremities non pitting [CONDITION(S)], resident looks pale. j. [DATE] at 2:10 PM, no output in Foley bag. The bag contained dry [MEDICATION(S)] in the bottom of the bag. Flushed the catheter with no fluid return. As the catheter balloon was deflated, 60 cc of foul brown urine with sediment returned. Doctor notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A 14 day comparison of urine output documented in the MAR showed that from [DATE]th-31st the average daily output from the resident's urinary catheter was 922 milliliters (ml). From [DATE]st through the 14th the average daily output was 666 ml. A hospital report dated [DATE] at 3:13 p.m., the resident presented to the emergency room (ER) for decreased urine output and [CONDITION(S)] (,d+[DATE]). The report revealed the resident's lung sounds were diminished. The assessment from the ER was severe [CONDITION(S)], likely secondary to [CONDITION(S)]. A laboratory report on [DATE] at 1:05 PM revealed the resident with a critical high white blood count, large amount of blood in the urine, creatinine level of 3.1 milligram to deciliter of blood (mg/dl). (Normal creatinine level for men is between 0.,d+[DATE].35 mg/dl.) The laboratory report dated [DATE], identified the Blood Urea [MEDICATION(S)] (BUN) as 69 mg/dl with normal range being ,d+[DATE] mg/dl. Creatinine and BUN levels are used to measure kidney function. A comparison laboratory tests on [DATE] showed that the resident's creatinine level was 1.6 and BUN was 41 mg/dl. On [DATE] at 6:03 PM Staff A LPN stated she felt very concerned about the progression of illness that led to the death of Resident #113. Staff A stated she told the DON the resident had little to no urinary output from the catheter. She said that she called the doctor on [DATE] but when she came back to work on [DATE], she found the resident still did not have any output that day and no response from the doctor. She said that she called and got an order to send him to the hospital. She said that the resident was not getting hydrated and his input was not monitored. On [DATE] at 4:08 PM the primary care physician stated in the days leading up to resident's hospitalization , he had some increased confusion and his condition declined rapidly. The doctor said the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked about the decrease in intake and output the doctor said that in retrospect, if he had known about the decrease in output, he may have ordered some labs and gotten the resident some intravenous (IV) fluids started. He said that he did believe the source of the [CONDITION(S)] was the [CONDITION(S)]. On [DATE] at 05:06 PM the DON stated she expected nurses to recognize if/when there is a change in urine output for a resident and to call the doctor at that time. She stated that they do not monitor or document fluid intake unless there is a specific doctor's order. 4. A MDS dated [DATE] assessed Resident #002 with a BIMS score of 0, (severe cognitive deficits). The resident required extensive assistance of two staff for transfers and toileting and one staff assistance for dressing and eating. A care plan dated [DATE] identified the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan indicated that the resident required assistance with activities of daily living due to a self-care deficits. A nursing note dated [DATE] at 7:08 AM showed that Resident #003 had audible wheezes in the lungs, chest congestion and his oxygen saturation was between 87%-90%. The doctor was contacted. A physician fax showed that the information filled out and signed by the nurse on [DATE] at 7:13 AM and a response from the doctor was not received until [DATE] at 8:35 AM. The chart lacked any documentation of follow up lung assessments. A nursing note dated [DATE] at 7:11 PM revealed the resident acting unusual. Staff obtained vital signs and the resident's blood pressure measured ,d+[DATE], pulse 116 beats per minute and oxygen saturation of 68%. Staff administered supplemental oxygen and the resident transferred to the hospital A hospital report signed on [DATE] at 5:10 PM. revealed Resident #003 presented to the ER room on [DATE] at 7:25 PM and expired on [DATE] at 10:15 AM. The primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 7:47 AM the DON stated if a doctor did not respond to a fax from the facility within 24 hours, it was the nurse's responsibility to send another request. If there was no response after the second request, the nurses should follow up with a phone call to the doctor.

Based on observation, staff and resident interview and record review the facility failed to ensure residents received adequate monitoring and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents #17, #40, #109 and #34 had incomplete skin evaluations and/or missed wound treatments. The facility reported a census of 55 residents. Findings include: The MDS (Minimum Data Set) assessment identified the definition of pressure ulcers: Stage I : intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II : partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. 1. A Minimum Data Set (MDS) dated [DATE] assessed Resident #17 with a Brief Interview for Mental Status (BIMS) score of 15 (no cognitive impairment). The resident required extensive assistance of two staff for bed mobility, transfers, toileting and bathing. A nurses note dated 2/19/21 at 3:41 PM revealed Resident #17 admitted to the hospital for infection of the lower left extremity wounds. A nursing note dated 3/1/21 at 11:00 PM indicated that he returned to the facility at that time. The care plan updated on 6/21/21 showed Resident #17 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan was updated on 9/1/21 to include that the resident was at risk for falls due to poor balance and needed prompt response to all request for assistance. The care plan showed the resident at risk for skin breakdown and pressure injury. Staff were instructed to assess the skin, monitor wounds daily, and to provide treatment to skin areas as ordered. On 10/28/21 at 07:59 AM, Resident #17 stated the dressing on his left foot had only been changed one time the previous day. The resident said that the treatment should be completed twice a day and it wasn't always getting done. A review of the electronic Treatment Administration Record (TAR) revealed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. An order dated 11/6/20 at 7:00 AM to cleanse buttocks with wound cleanser and soap and water one time a day. The TAR lacked documentation staff completed the treatment on 12/1/20 and 12/4/20, 1/6/21 and 1/7/21. b. Order on 9/26/20 at 7:00 AM to cleanse the left heel ulcer with normal saline, paint with [MEDICATION(S)], cover with ABD and wrap with Kerlix daily. The TAR lacked documentation that staff completed the treatment on 12/1/20, 12/420, 12/920, 1/6/21 and 1/7/21. c. Order dated 9/26/20 at 7:00 AM to cleanse the right heel with saline, apply Santyl ointment, cover with [MEDICATION(S)] and cover with 0.125 Dakins soaked gauze, apply layer of dry gauze or Kerlix and wrap with Kerlix every day. The TAR lacked documentation that staff completed the treatment on 12/1/20, 12/4/20 and 12/9/20. d. Order dated 9/26/20 at 7:00 AM to cleanse the right lateral lower leg ulcer with saline, apply [MEDICATION(S)], apply gauze and wrap with Kerlix every day. The TAR lacked documentation that staff completed the treatment on 12/1/20, 12/4/20, 12/9/20, 1/6/21, 1/7/21 and 2/1/21. e. Order dated 11/23/20 at 8:00 AM for the left foot top 3 times a week [MEDICATION(S)] border in the morning on Monday, Wednesday and Friday. The TAR lacked documentation that the treatment was completed on Friday, 12/4/20, Wednesday 12/9/20 or Wednesday 1/6/21. f. Order dated 2/22/21 at 11:54 AM to cleanse bilateral heels and top of the left foot with normal saline, then apply Santyl ointment cover with [MEDICATION(S)] and then Dakins soaked gauze, cover with AND pad and wrap with gauze, secure with tape daily two times a day. The TAR lacked documentation that the treatment was completed on 2/8/21. 2. A MDS dated [DATE] assessed Resident #109 with a BIMS score of 9 (severe cognitive deficits). The MDS showed that the resident required extensive assistance with the help of two for transferring, bed mobility and toileting. A care plan updated on 1/25/21 directed staff to observe skin integrity and notify the doctor of breakdown. The care plan indicated that the resident had an unhealed stage 2 pressure injury and a pressure reducing mattress was in place. The electronic record included an order dated 1/25/19 at 10:45 for [MEDICATION(S)] ointment 0.44-20.8% ([MEDICATION(S)]-[MEDICATION(S)]) to apply to buttocks topically every 12 hours as needed for prevention of skin breakdown. According to the Treatment Administration Record (TAR) the preventative treatment was not used at all in the months of November or December 2020. In a document titled: Weekly Pressure Ulcer Progress Report dated 12/1/20 an area of new skin breakdown was discovered on the coccyx. The documentation indicated that it was a stage II pressure, but the documentation lacked measurements or descriptions of the injury. On 12/7/20 the area was measured at 2.1 centimeters (cm) x 1.5 cm and 0.2 depth with a foul smell. According to a fax sent to the doctor on 12/3/20 at 7:00 AM the resident had a stage II pressure area on the coccyx. The communication lacked measurements or description of the wound. The doctor's response on 12/3/20 was to continue current treatments and medications. The chart lacked any treatment orders for the coccyx wound. A fax to the doctor dated 12/7/20 at 4:00 revealed the resident with an ulcer to the coccyx and and staff applied a [MEDICATION(S)] treatment (an absorbent foam dressing for wounds) at that time. The physician responded on 12/8/21 that it was okay to continue a [MEDICATION(S)] treatment every 3 days. According to the TAR the [MEDICATION(S)] treatment to the coccyx wound did not start until 12/10/20. An admission report from the hospital dated 12/21/20 identified Resident #109 with a stage IV sacral decubitus ulcer and multiple bilateral lower extremity ulcers with fat layer exposed. 1. Sacral pressure injury stage 4 measured 2x2x2.5 centimeters (cm) with undermining of 3.3cm. [CONDITION(S)] surrounding the wound that measured 6x6cm. foul order from the wound. 2. Skin tears on the clavicle on the right side measure 1x1.5cm with red wound bed. 3. Skin tear on clavicle left measured 3x2cm 4. Left upper arm skin tear measured 6x5cm 5. Next to the upper arm skin tear a smaller tear measures 1x1cm 6. Right upper arm skin tear measure 8.5x2cm pale pink wound bed. 7. Right distal lateral thigh skin tear measures 0.8x1.1cm 8. Right lateral/anterior knee large skin tear measures 6x7cm with some epithelized tissue. Open area measure 2.5x4cm 0.7x0.5cm. 9. Right lateral knee skin tear 1.5x3cm with red wound bed. 10. Right proximal lateral /anterior lower leg skin tear measures 2x2cm with red wound bed. 11. Right proximal anterior lower leg skin tear measured 4x3cm with some epithelial tissue and pink wound bed. 12. Left lower anterior lower leg skin tear measure 2x0.5cm with some epithelial tissue. 13. Left proximal anterior lower leg measure 3.5x3.5cm According to the November and December 2020 TAR of the above skin wounds, the resident received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. A MDS dated [DATE] assessed Resident #40 with a BIMS score of 11 (moderate cognitive deficits). The MDS showed that the resident required limited assistance with the help of one for transfers, walking, locomotion, dressing and toileting. The care plan dated 7/9/21 included a focus area related to skin integrity and showed that the resident was at risk for skin breakdown related to frequent incontinence and directed staff to provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation showed on 11/2/21 at 11:43 Resident #40 in his wheel chair near the nurse's station. The wheel chair did not have a pressure reducing mattress in the wheel chair. An undated document titled: Skin and Wound Management Program Overview, directed staff to assess the residents weekly for skin breakdown. Once a break in skin integrity was identified the nurse was to document size, stage, location, drainage, and odor of area. The documentation was to include treatment orders and a detailed care plan. The care plan was to be implemented and re-evaluated to minimize risk for further injury. 4. The Quarterly MDS dated [DATE] assessed Resident #34 with (BIMS) score of 15 (intact cognition). The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation revealed the resident required extensive assistance of 2 staff with bed mobility, and limited assistance of 1 staff with Activities of Daily Living (ADLs) and locomotion per walker or wheelchair. The MDS identified the resident as having a Stage 2 pressure ulcer ( painful damaged skin). The care plan dated 09/20/21 identified the resident at risk for skin problems with a stage 2 pressure ulcer to her left buttock. It directs staff to provide wound treatment as ordered, skin assessments updated weekly and as needed until the area is healed. The clinical record revealed Staff NN sought a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A faxed communication, dated 10/06/21 and signed by the physician on 10/26/21, directed staff to apply [MEDICATION(S)] BID (twice daily) and PRN ( as needed). On 11/02/21 at 08:46 AM, the DON reviewed the electronic medical record for the physicians order dated 10/25/21 that directed [MEDICATION(S)] to applied to the residents pressure ulcer. The DON acknowledged the order not entered into the electronic medical and the resident did not receive the updated prescribed treatment as ordered. The DON stated she expected staff to note faxes returned, if there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON acknowledged this process was not followed.

Based on record review, observation, staff and resident interview, the facility failed to provide adequate nursing supervision to prevent injuries for 8 of 36 residents reviewed (Residents #16, #33, #40, #48, #50, #110, #00 and #112). The facility reported a total census of 55 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] assessed Resident #16 with a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive impairment). The MDS identified the resident with the following sign of delirium: disorganized thinking that fluctuated. The MDS identified the resident as independent with transfer, ambulation and toileting. A balance during transitions and walking identified the resident as steady at all times in all areas of testing. The resident used a walker with ambulation. The resident was occasionally incontinent of bladder and continent of bowel. The MDS identified no trial of scheduled or prompted toileting attempted. The resident had diagnoses that included: nontraumatic [CONDITION(S)] and repeated falls. The resident admitted to the facility 12-12-19. Facility incident reports (IR) from 12/2020- 10/2021 revealed Resident #16 had falls on the following dates: 12/4/20 12/7/20 12/19/20 1/8/21 1/13/21 3/27/21 5/26/21 6/13/21 6/26/21 8/7/21 9/22/21 10/12/21 10/20/21 Review of the Morse Fall Scales completed revealed the following information: 9/24/20- score of 65 indicates a high risk for falling 12/24/20- score of 80 indicates a high risk for falling 3/24/21- score of 80 indicates a high risk for falling 6/22/21- score of 80 indicates a high risk for falling 8/13/21- score of 75 indicates a high risk for falling 8/31/21- score of 75 indicates a high risk for falling An IR dated 12/4/20 at 10:42 p.m. revealed an unwitnessed fall in the resident's room. Staff found Resident #16 laying on the floor next to her bed. Resident #16 stated she had to go to the bathroom. The resident stated she hit her left shoulder, arm, leg and also her back. The resident had a puncture wound on her forehead above her right eyebrow measuring 0.5 centimeters (cm.) by 0.5 cm. Staff cleaned the wound and covered it with a Band-Aid though the resident had documented injury, the IR stated no injuries observed post fall. The IR identified the resident ambulating without assistance, wearing improper footwear and gait imbalance. The resident used a walker. The report lacked an intervention put into place immediately following the fall and notification of the physician or Resident #16 ' s power of attorney. There was no investigation as to when staff last saw the resident or when staff last assisted the resident to the toilet. There was no investigation to identify if the resident's call light was available or if she activated the call light. Resident #16's care plan with a revision date of 8/26/2020 revealed she transferred with a walker and one staff assist for safety to and from the bathroom. Offer toileting before and after meals and at request initiated 12/17/2019. Resident #16 is to ambulate with one assist and walker as tolerated effective 12/17/2019. Reinforce use of call light to request assistance initiated 12-1917-19. Resident #16's care plan lacked intervention for the 12/4/20 incident. A neurological (neuro) assessment flow sheet revealed empty boxes on the following: 12/6/20- day shift 12/6/20- evening shift 12/7/20- day shift 12/7/20- evening shift The 12/7/20 neuro assessment identified the resident as drowsy and the right hand grasps were greater than the left hand grasp. Review of Resident #16's progress notes revealed the chart lacked documentation of the 12/4/20 incident. An IR dated 12/7/21 at 1:06 a.m. revealed an unwitnessed fall in the resident's room. A nurse aide alerted the nurse that the resident fell . Upon entering the room, staff observed the main room light off but the bathroom light on. The resident was on the ground on her left side and from the waist up was under her roommates bed. The resident had one shoe on and her walker was next to her. Staff observed a head wound with moderate blood loss of approximately 100 ml. The residents pupils were pinpoint and nonreactive. No other injuries were noted. The other nurse on duty contacted EMS (emergency medical services) and the resident transported to the hospital for evaluation. The resident stated she attempted to stand to go to the bathroom and her feet got tangled up with themselves. She stated she hit her head on the bedside table and she didn't think she passed out. When asked how she got under her roommates bed, she stated she tried to move away from the blood because she didn't want it on her sweater. The IR identified the resident as an assist of one due to fracture of the left wrist and inability to hold the walker with both hands. There was no investigation as to when staff last saw the resident or when staff last assisted the resident to the toilet. There was no investigation to identify if the resident's call light was available or if she activated the call light. Review of neurological assessment flow sheet revealed empty boxes on the following: 12/7/20- 1:45 a.m. Level of consciousness Pupil response Vitals Observations 12/9/20- day shift 12/9/20 evening shift 12/10/20- night shift The neuro assessment dated [DATE] for the night shift, day shift and evening shift revealed right hand grasps were greater than the left hand grasps. Resident #16's progress notes revealed on 12/7/20 at 4:44 a.m., Resident #16 returned from the ER with 11 staples to the right side of her head and a fracture to the left wrist and needed to schedule a follow up with the provider as soon as possible. A nonpressure skin report dated 12-7-20 identified a head wound in reverse C shape measuring 11.4 cm. and 11 staples. The wound contained an open area measuring 9 cm. by 0.2 cm. A nonpressure skin condition report dated 12-7-20 identified a 1.1 cm. by 2.2 cm. light brown bruise present from the fractured left wrist that occurred that morning. The report identified the resident experienced pain from the fracture. Resident #16's care plan with a revision date of 8/26/2020 revealed contained a revision dated 12-7-20 that identified the resident as up ad lib in her room. Offer toileting before and after meals and at request. This intervention reduced supervision of the resident and did not address increased toileting even though the resident continued to fall when toileting self. An IR dated 12-19-20 at 8:30 p.m. revealed an unwitnessed fall in the resident's room. Upon entrance to the resident room, staff observed the resident on the floor next to her bed with both legs straight out. Resident #16 stated tried to sit on the edge of the bed. No injury observed. The IR identified the resident with gait imbalance and impaired memory. The resident wore improper footwear and ambulated without assistance. Observation at the time of the fall, showed the resident wore silky socks when the fall occurred. There was no investigation as to when staff last saw the resident or when staff last assisted the resident to the toilet. There was no investigation to identify if the resident's call light was available or if she activated the call light. Resident #16's record lacked documentation of a neurological assessment flow sheet. Resident #16's progress notes revealed the chart lacked documentation of the 12/19/20 incident and notification of physician and Resident #16's power of attorney. Resident #16's progress notes revealed a note on 12/21/20 at 9:50 a.m., fall review completed and the intervention was to place gripper strips in front of bed to prevent slipping. Review of the care plan revealed the care plan failed to contain this intervention. The care plan did not identify any new corresponding interventions after the incident. A Minimum Data Set (MDS) dated [DATE] assessed Resident #16 with a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive impairment). The MDS identified the resident with the following sign of delirium: disorganized thinking that fluctuated. The MDS identified the resident required limited staff assistance with transfers and toileting. The resident ambulated with supervision in room and corridor. A balance during transitions and walking identified the resident as not steady but able to stabilize without staff assistance in all areas of testing. The resident used a walker with ambulation. The resident was occasionally incontinent of bladder and frequently incontinent of bowel. Progress notes dated 1-8-21 at 4:55 p.m. revealed the resident was in the dining room trying to go up a ramp by the window when her walker slid away and the resident fell backwards. Two staff witnessed the incident. The resident did not hit her head. She received a 4.5 cm. by 1.5 cm. bruise to the top of the hand. She complained of pain in the low back at 3, on a scale of 0 to 10 with 0 being no pain and 10 being the worst imaginable pain. The care plan identified an intervention dated 1-11-21 that directed staff to not leave the resident unattended in the dining room to prevent unassisted ambulation on the ramp. An IR dated 1/13/21 at 2 a.m. revealed an unwitnessed fall in the resident's room. Staff found the resident on the floor of her bathroom. There was urine and paper in the toilet with the resident on the floor with pants and pull ups down past her knees. The resident laid on her left side. The resident stated she was done going to the bathroom and tried to pull up her pants and slipped on the floor. No injury observed. The IR identified the resident with gait imbalance and ambulating without assistance. There was no investigation as to when staff last saw the resident or when staff last assisted the resident to the toilet. There was no investigation to identify if the resident's call light was available or if she activated the call light. Review of neurological assessment flow sheet revealed empty boxes on the following: 1/13/21- 6:45 a.m., left hand grips were greater than the right hand grasps 1/13/21- 7:45 a.m., left hand grips were greater than the right hand grasps 1/13/21- 8:45 a.m., left hand grips were greater than the right hand grasps 1/13/21- evening shift, left hand grips were greater than the right hand grasps and pain response box was empty 1/14/21- night shift, left hand grips were greater than the right hand grasps 1/14/21- day shift, left hand grips were greater than the right hand grasps 1/14/21- evening shift, left hand grips were greater than the right hand grasps 1/15/21- night shift hand grasps was empty Review of Resident #16 ' s progress notes revealed the following: 1/13/21 at 2:14 a.m., Resident #16 was found on the floor, she was encouraged to use her call light for assistance in the bathroom. 1/13/21 at 9:16 a.m. revealed fall committee meeting was held and decided Resident #16 needed to wear a gown to bed as she frequently toilets herself and it is difficult for her to pull up her pants when she is not fully alert. The entry lacked notification of Resident #16 ' s power of attorney. The care plan did not identify any new corresponding interventions after the incident. Review of Resident #16's MDS dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. The MDS revealed the Resident #16 needs supervision from the staff and setup assistance with toileting. Resident #16 was not on a urinary or bowel training program. An IR dated 3/27/21 at 10:35 p.m. revealed an unwitnessed fall in the resident room. Staff found the resident laying on her right side on the bathroom floor with shoe off the right foot. Staff assisted the resident off the floor and observed a scrape to the midback between shoulder blades. The resident rated pain at 7. Resident #16 stated she lost her balance when she tried to go back to bed. The resident did not use her walker. There was no investigation as to when staff last saw the resident or when staff last assisted the resident to the toilet. There was no investigation to identify if the resident's call light was available or if she activated the call light. The neurological assessment flow sheet revealed empty boxes on the following: 3/30/21- evening shift 3/30/21- night shift Review of the progress notes revealed the following: Chart lacked documentation of the 3/27/21 incident Lacked notification of Resident #16's physician 3/28/21 at 7:40 a.m., Resident #16's power of attorney informed of recent falls. Review of Resident #16's care plan with a revision date of 12/21/2020 revealed an addendum dated 3/29/21 to place sign in room stating DON'T FORGET TO USE WALKER. There was no change in interventions to provide increased supervision and/or increased toileting assistance. An IR dated 5/26/21 at 11:46 p.m. revealed an unwitnessed fall in the resident's room. Staff found the resident laying on her left side at the foot of her bed. Observation revealed bleeding coming from the top/front of the resident's head. The resident was confused and unable to state what happened. Resident #16 noted to have an abrasion to the top of the scalp and was transported to theER on [DATE] at 2:25 a.m. The IR also identified injury to left fingers-bruise observed to left hand second digit/knuckle. The IR identified the resident with gait imbalance and impaired memory. The resident was ambulating without assistance during a transfer. The box beside clutter was not checked as a factor in the fall. There was no investigation as to when staff last saw the resident or when staff last assisted the resident to the toilet. There was no investigation to identify if the resident's call light was available or if she activated the call light. Progress notes dated 5-27-21 at 5:42 a.m. revealed the resident returned from the hospital at 5:18 a.m. Review of neurological assessment flow sheet revealed empty boxes on the following: Undated column for evening shift 5/29/21- day shift 5/29/21- evening shift 5/30/21- night shift Progress notes revealed the following: Chart lacked documentation of the 5/26/21 incident 5/27/21 at 9:14 a.m., revealed fall committee meeting intervention will be to declutter the room and reorganize it for safety. Review of Resident #16's care plan contained an intervention dated 5-27-21 to keep room free of clutter and arrange for safety. There was no change in interventions to provide increased supervision and/or increased toileting assistance. An IR dated 6/13/21 at 10:12 p.m. revealed an unwitnessed fall in the resident's room. Staff found the resident at 8:45 p.m. laying on her right side in the bathroom. The resident stated she was tried to use the bathroom and forgot her walker. No injury observed. The IR identified the resident with gait imbalance and weakness. There was no investigation as to when staff last saw the resident or when staff last assisted the resident to the toilet. There was no investigation to identify if the resident's call light was available or if she activated the call light or if the sign to use the walker was in her room. The neurological assessment flow sheet revealed empty boxes on the following: 6/16/21- night shift 6/16/21- day shift 6/16/21- evening shift Resident #16's progress notes revealed the following: 6/13/21 resident was found on the floor in her bathroom on her right side. Resident #16 noted to have a small bump on the forehead. 6/20/21 at 7:02 a.m. revealed resident requires assistance with hygiene and transfers to prevent falls. Review of Resident #16 ' s care plan following the 6/13/21 fall revealed no intervention change to provide increased supervision and/or increased toileting assistance. An IR dated 6/26/21 at 7:20 p.m. revealed an unwitnessed fall in the resident's room. Resident #16 was found on the floor in her bathroom. Resident #16 revealed she lost her balance while she was walking to the bathroom. No injury observed. The IR identified the resident with gait imbalance and weakness. There was no investigation as to when staff last saw the resident or when staff last assisted the resident to the toilet. There was no investigation to identify if the resident's call light was available or if she activated the call light. The neurological assessment flow sheet revealed the following information: Initial assessment was completed on 6/26 at 6:50 p.m. Second assessment was completed on 6/26 at 7:50 p.m. 6/29/21 night shift assessment revealed the right grasp is greater than the left grasp. 6/29/21- day shift no information recorded. 6/29/21- evening shift no information recorded. Resident #16 ' s progress notes revealed the following notes: 6/26/21 at 7:38 p.m., Resident #16 was found sitting on her bathroom floor. Resident #16 revealed she lost her balance while walking to the bathroom. No injuries noted with the fall. 6/26/21 at 10:14 p.m., revealed Resident #16 is forgetful to use call light and independent with activities of daily living. 6/28/21 at 1:00 p.m., revealed a fall committee meeting with intervention for fall on 6/26/21 will be to fax the doctor for labs and to have therapy to a screen. 6/29/21 at 4:52 a.m., revealed resident is alert to self and continues to transfer self without calling for assistance. 6/30/21 at 8:26 p.m., revealed an order for Part B physician therapy to evaluate and treat. Copy given to the therapy department. Review of Resident #16 ' s care plan after the 6/26/21 fall revealed no intervention change to provide increased supervision and/or increased toileting assistance. Review of Resident #16's MDS dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. The MDS revealed the Resident #16 limited assistance and one person physical assistance with toileting and supervision with ambulation in room, and limited assistance with ambulation in corridor. A balance during transitions and walking identified the resident as not steady but able to stabilize without staff assistance in all areas of testing. The resident used a walker with ambulation. The resident was occasionally incontinent of bladder and continent of bowel. Resident #16 was not on a urinary or bowel training program. A health status note dated 8-5-21 at 9:58 a.m. identified the resident with a condition change. The resident was weak, cold and difficult to open eyes. The resident could not stand. The resident transported to ER for evaluation on 8-5-21 and returned on the same date at 2:50 p.m. with no new orders and make follow up appointment with primary care physician. An IR dated 8/7/21 at 11 p.m. revealed an unwitnessed fall in the dining room. Staff found the resident laying on the floor in the dining room next to the couch. The resident's head was against the wall while her left knee was on top of the other. Staff observed redness to the right hand. The knee was deformed, red and something protruded under her knee skin. The resident experienced pain with movement and rated the pain 9/10. 3 cm. swelling was noted on the resident's forehead. Staff tried to get the resident off the floor but noted the resident to be in severe pain as evidenced by screaming and facial grimacing. Staff called 911 and the resident transported o the hospital at 11:10 p.m. The resident stated she tried to sit on the couch. Review of neurological assessment flow sheet revealed empty boxes on the following: 8/7/21 at 10:45 p.m., extremities 8/7/21 at 11:00 p.m., extremities Review of Resident #16 ' s progress notes revealed the following: 8/7/21 at 11:41 p.m., Resident #16 found on the floor in the dining room next to the couch. Resident #16 revealed she tried to sit on the couch. Knee was noted to be deformed, red and something protruding under her knee. Staff tried to get the resident off of the floor but were unable to due to extreme pain. Resident #16 was sent to the ER for evaluation. 8/8/21 at 11:53 p.m., Resident in hospital at this time with admitting diagnosis of closed fracture to the left patella and resident's femur is shattered. Nurse states that the resident is currently in traction and is awaiting surgery. A hospital history and physical dated 8/8/21 at 2:36 a.m. revealed the chief complaint as: fall. The resident presented with externally rotated and shortened right lower extremity. On assessment the resident grimaced and writhed in pain. The physician could palpate bone shards through the medial aspect of the right knee indicating impending open fracture. The resident reported extreme pain with this. She also had a hematoma of the right forehead above the right eye. The principal problem was fractured right femur. X-ray showed a displaced comminuted femoral fracture. The resident underwent surgery: open reduction and internal fixation of the right extremity to repair the fracture. Progress notes revealed the resident readmitted to the facility 8-14-21 with nonweight bearing to the right leg due to fracture. The resident wears a hinged brace with leg elevated. The resident had narcotics ordered for pain control. Review of Resident #16 ' s MDS dated [DATE] revealed a BIMS score of 7 indicating severe cognitive impairment. The MDS revealed the Resident #16 is total dependence and two plus persons physical assistance with toileting. Resident #16 was not on a urinary or bowel toileting program. An IR dated 9/22/21 at 5 p.m. revealed an unwitnessed fall in the resident room. Staff found the resident on the floor in her bedroom. Staff noticed that the resident had blood on the back of her shirt and identified a 1 cm. by 0.5 cm. tear to the back of the head. The resident stated she wanted to go to bed. The resident was ambulating without assistance and had a urinary tract infection. There was no investigation as to when staff last saw the resident or when staff last assisted the resident to the toilet. There was no investigation to identify if the resident's call light was available or if she activated the call light. Review of neurological assessment flow sheet revealed empty boxes on the following: 9/22 at 5:15 p.m., signature 9/22 at 5:30 p.m., signature 9/22 at 5:45 p.m., signature 9/22 at 6:15 p.m., hand grasps 9/22 at 6:45 p.m., hand grasps 9/22 at 8:45 p.m., hand grasps 9/25 day shift 9/25 evening shift Review of Resident #16 ' s progress notes revealed the following: 9/22/21 at 6:45 p.m., staff found Resident #16 on the floor at 5:00 p.m Resident was found with a mild amount of blood on the back of her shirt. Noticed a tear on the back of her head. Call placed to physician and doctor order to continue to check resident vital signs and neuros every 4 hours and call back if her condition worsened. 9/23/21 at 9:19 a.m., revealed a fall committee meeting with the intervention for fall on 9/22/21 will be to have Resident #22 seen by a provider as soon as possible for a medication review. 9/23/21 at 9:46 a.m., revealed update on residents condition given to PACE and they will be out later this afternoon to see Resident #16. Review of Resident #16 ' s care plan with a revision date of 9/9/21 revealed she is unable to ambulate at this time with staff due to non-weight bearing status. Resident #16 requires extensive assistance of 1-2 using bedpan, dependent on assistance of 2 using the Hoyer lift to commode or toilet. Resident #16 requires Hoyer lift will assistance of 2 at this time due to non-weight bearing status following fracture with patella and femur fracture. Resident #16 is working with therapy to improve independence with toilet use, staff will offer toilet use before and after meals and with rounds on night shift and as needed initiated 8-31-21. The care plan revealed no intervention change to provide increased supervision and/or increased toileting assistance following the 9-22-21 fall. An IR dated 10/12/21 at 6 a.m. revealed an unwitnessed fall in the resident's room. Staff found the resident on the floor with head against the bathroom door. Resident #16 revealed she was on her way to the bathroom and hit her head in the fall. The resident motioned to the right posterior area of the head. No injury observed. The IR identified the resident with gait imbalance and impaired memory. The resident ambulated without assistance. There was no investigation as to when staff last saw the resident or when staff last assisted the resident to the toilet. There was no investigation to identify if the resident's call light was available or if she activated the call light. Review of neurological assessment flow sheet revealed empty boxes on the following: 10/13- evening shift respirations 10/14- day shift 10/14- evening shift 10/15- night shift 10/15- day shift Review of Resident #16's progress notes revealed the following: the chart lacked documentation of the 10/12/21 incident, notification of the physician and notification of Resident #16 power of attorney. 10/12/21 at 3:41 p.m., revealed the fall committee met and the intervention for the fall is if staff observes Resident #16 to be up and not sleeping while in bed. Staff is to offer to get her up and out of bed. An IR dated 10-20-21 at 3:40 a.m. identified an unwitnessed fall in the resident's room. Staff found the resident laying on the bathroom floor in a semi fetal position on her left side. The resident's head laid under the bathroom sink with the left arm under her head and gripper socks on. Staff assessed a 2.5 cm. by 3 cm. bump on the left side of the resident's head. Resident #16 revealed she was trying to go to the bathroom and didn't make it. She hit her head but not sure on what. Brief on the floor next to the bed. Bedding and brief wet. The IR identified the resident with gait imbalance and impaired memory. The resident ambulated without assistance. There was no investigation as to when staff last saw the resident or when staff last assisted the resident to the toilet. There was no investigation to identify if the resident's call light was available or if she activated the call light. Review of neurological assessment flow sheet revealed empty boxes on the following: 10/20 at 6:25 a.m., signature 10/21- day shift 10/21- evening shift- level of consciousness was drowsy 10/21- night shift- level of consciousness was drowsy 10/23- night shift Review of Resident #16 ' s progress notes revealed the following: 10/20/21 at 7:50 a.m., resident found lying on the bathroom floor. Resident was noted to have a bump to the right side of the head. Resident reports having a headache for the last 2 days. Resident reports she was going to the bathroom. 10/20/21 at 9:29 a.m., fall committee met and intervention for the fall will be to add anti-rollbacks to the wheelchair, and to keep the wheelchair within reach and bed in a regular position. Review of Resident #16 ' s care plan revealed no intervention change to provide increased supervision and/or increased toileting assistance. Observation: Observation showed on 11/02/21 at 12:47p.m., Staff N, CNA and Staff GG, CNA assist Resident #16 to the bathroom. Staff N, CNA the resident if she could sit forward and Staff N, CNA applied the gait belt. Staff N, CNA and Staff GG, CNA assisted Resident #16 to a standing position. Resident #16 shuffled her feet to the right to get to the toilet and pivot transferred to the toilet. Staff GG, CNA assisted Resident #16 to sit onto the toilet. No observations of verbal or non-verbal signs of pain with the transfer. Review of facility policy tilted Accident and Incidents Unplanned Occurrence Reports with a revision date of April 2019 revealed accident, incident, or unusual occurrences involving residents, employees, or visitors occurring on the premises must be investigated and reported to the administrator. Regardless of how minor an accident or unusual occurrence may be, including injuries of unknown source, it must be reported to the department supervisor as soon as such occurrence is discovered or when information is learned. A risk management report must be completed for all reported accidents, incidents or unusual occurrences. The nurse supervisor or charge nurse shall examine the person involved in accident, incident or unusual occurrence, notify the medical director or the person or persons resident's personal or notify the resident ' s responsible party of the occurrence. The nurse supervisor, charge nurse, or department director of supervisor must complete an immediate investigation of the occurrence. Place a note on the 24 hour report related to the occurrence with the resident. The time the injured persons attending physician was notified as well as the time the physician responded and his or her instructions. Include any corrective action taken and follow up information. Treatment and follow up interventions will be determined according to the practicing physician and the caregiving team. On 11/02/21 at 01:20 p.m., the Director of Nursing (DON) revealed that neurological checks are to be initiated with all unwitnessed falls and falls with head injuries. Neurological checks are to be started at the time of the fall. On 11/09/21 at 02:44 p.m., the DON revealed the physician and power of attorney need to be notified at the time of the fall. This information needs to be charted in the progress notes. The incident report is not part of the medical record. Neurological checks need to be completed for a minimum of 72 hours. 2. A MDS dated [DATE] assessed Resident #110 with a BIMS score of 7 (severe cognitive deficits). The resident required extensive assistance of one staff for transfers, dressing and toileting. The resident had wandering behaviors and required the assistance of a walker and/or wheelchair at times. The resident had diagnoses that included: [CONDITION(S)], urinary tract infection and muscle wasting. The resident received [MEDICATION(S)] (anticoagulant) 3 milligrams (mg.) daily. A baseline care plan dated 6/28/21 showed Resident #110 admitted to the facility on that date with no history of falls. The care plan directed staff should to monitor for wandering and exit seeking behaviors. The area of safety contained no directives. The care plan did not contain toileting directives other than the resident required the assistance of one staff to toilet. A care plan dated 7/9/21 identified the resident with limited physical mobility related to balance deficit, required the assistance of one for ambulation and could propel self in a wheel chair. The care plan included a focus area of questionable exit seeking potential. The care plan identified the resident as forgetful. The care plan did not contain an addendum dated 7/2/21 to place a sign in room to remind resident to activate the call light if she required assistance. The care plan failed to address the resident did not wait for staff toileting assistance (as evidenced by her getting up without assistance to the bathroom on 7-2-21) A nursing note dated 6/30/21 at 10:24 AM identified the resident as not capable of making safe, realistic or logical decisions for herself. An IR dated 7/2/21 at 5:15 AM revealed Resident #110 got up and tried to get to the bathroom without activating the call light and without assistance. Staff T CNA (certified nurse aide) reported he assisted the resident with a sponge bath at 4:40 AM that morning, assisted her to the toilet, put her in a recliner chair with the call light next to her and left the room to assist another resident. He documented that 15 minutes later he heard Resident #110 yelling for help and found her sitting on the floor in front of the recliner. Progress notes dated 7/2/21 at 8:50 a.m. revealed the fall committee met and directed therapy to place a sign in the residents room to remind her to use the call light. The following is a list of nursing notes after the 7/2/21 fall: a. 7/2/21 at 8:00 AM; Dr. informed of the fall and staff were directed to send to the hospital [TRUNCATED]

Based on clinical record reviews, reviews of manufacturer's guidelines and interviews, the facility failed to provide adequate nursing supervision and training to prevent accidents for 2 of 9 sampled (Residents #1 and #9). The facility reported a census of 76. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. Resident #1 had severe cognitive impairments. Resident #1 required extensive assistance of 2 staff for bed mobility, transfer, dressing hygiene, toilet use, bathing and wheelchair mobility. The Care Plan dated 9/15/17 identified Resident #1 dependent on staff for all activities of daily living and directed staff to transfer Resident #1 with a sit to stand lift and move the foot platform midline for ease of transfer. The Progress Note dated 4/7/19 at 11:15 p.m., completed by Staff D, (Licensed Practical Nurse) documented at 8:45 p.m., Staff A (Nurse Aide) and Staff B (Nurse Aide) reported they attempted to transfer Resident #1 to bed with a sit to stand lift. Staff A and Staff B had Resident #1 up in the lift when the handle on the lift stuck and failed to lower. Staff A and Staff B attempted to lower Resident #1 into her wheelchair. Resident #1's foot slipped off the foot platform. Staff B assisted Resident #1 to sit on the floor against the bed. Staff A and Staff B reported Resident #1 did not hit her head. Staff [NAME] (Registered Nurse) assessed Resident #1 and noted no injuries. Staff notified Resident #1's husband of the incident. During interview on 8/21/19 at 3:40 p.m., Staff A stated that she and Staff B transferred Resident #1 from the wheelchair to bed. Resident #1's husband left the room when the staff started to transfer Resident #1. Staff A placed the lift harness behind Resident #1 and attached it to the sit to stand lift. Staff A did not fasten the safety belt of the harness around Resident #1's waist because it was common knowledge that her husband did not want it used. Resident #1's husband felt it was too tight around her. Staff A lifted Resident #1 up with the lift. Staff A and Staff B noticed Resident #1's right foot slid off behind the platform. Staff A could not position the lift near the bed or wheelchair due to Resident #1's foot. Resident #1weakened and started to slip out of the unfastened harness. Staff B positioned herself behind Resident #1 and lowered Resident #1 to a sitting position on the floor. Staff A stated the lift malfunctioned. Once extended it suddenly would not operate. Staff A did not activate the emergency stop switch. Staff A attempted to use the manual button to lower the lift but it failed. Staff A reported they were scrambling because Resident #1 weakened. Staff A stated said she did not know the lift had a safety strap/sling that could go under the resident's buttocks if they were sliding down until she received education on it after the incident. During interview on 9/5/19 at 1:50 p.m., Staff B stated she assisted Staff A to transfer Resident #1 with the sit to stand lift without the safety harness fastened. Staff B reported Resident #1's spouse asked them on prior occasions not to fasten the safety harness. On the day of the incident, she and Staff A were getting ready to transfer the resident from the wheelchair to her bed. Her spouse had been there but left before the transfer. Staff B said she then went behind the resident's wheelchair because Staff A had the controls of the lift. She stated the EZ Stand lifted the resident to a standing position and suddenly the lift would not work and the resident's buttocks started to go down. She stated she had to do something so she moved the wheelchair and saw the resident's right foot on the back raised edge of the footrest. She stood behind the resident and she slid down her torso and legs and sat on the floor. Staff B stated the resident slid down slowly with her body supported. Staff B stated the resident sat on the floor and her lower legs supported her back. During an observation 9/5/19 at 1:50 p.m., the surveyor obtained and EZ Stand from the facility and acted as Resident #1 and requested Staff B do everything as she had done for Resident #1 on the night of the incident. Staff B placed the harness around the surveyor's back. Staff B failed to fasten the safety belt and the calf strap. When questioned why she did not fasten the safety belts, Staff B reported she thought Staff A did because she had control of the lift. The Progress Note dated 4/8/19 at 11:37 a.m., completed by Staff C (Registered Nurse), documented Resident #1 had right leg pain when staff touched or reposition the right leg, exhibited lethargy and could not focus when spoken to. At 10:45 a.m., Resident #1's spouse transported her to a doctor's appointment. A Progress Note dated 4/8/19 at 8:07 p.m., revealed Resident #1 admitted to the hospital with [REDACTED]. The History & Physical dated 4/8/19, revealed Resident #1 admitted to the hospital [MEDICAL CONDITION]ly from urinary tract, [MEDICAL CONDITION], and acute [MEDICAL CONDITION] aspect of the right medial femoral condyle with mild-to-moderate fragment separation. The X-Ray Report dated 4/8/19 documented Resident #1 had osteopenic bones. The X-ray report of the right knee dated 4/8/19 documented the distal femur fracture just above the femoral component of knee arthroplasty, worrisome for acute fracture. The EZ Way Smart Stand Manufacturer Operator's Instructions directed the following: Attach harness: 1. Position the harness around the upper body of the patient so the sides of the harness are between the patient's torso and arm resting 2-3 inches below the underarm. 2. For the safety of the patient, securely fasten the safety strap around the patient's torso. 3. Secure the buckle and pull the strap to tighten. Attach harness to the EZ Way Smart Stand: With the lift arm in the lowest position, attach the harness to the hooks at the end of the EZ Way Smart Stand arm using the loops at the end of the harness. Use the shortest loops when possible. To ensure the patient safety and comfort, make sure you use the same color loop on each side. Raise the patient: 1. Position the patient's arms on the outside of the harness and have tem lace their hands on the padded handles. 2. With the hand control in-hand, stand beside the patient. Verify the loops are properly hooked inside the pigtail at the end of the EZ Way Smart Stand arms and the Safety Catch is in place, blocking the strap from exiting the pigtail. Press the UP button, as the patient is raised, simultaneously tighten the safety strap buckled around their torso. During interview on 8/23/19 at 2:45 p.m., the Maintenance Supervisor stated the emergency switch on the lift used during the incident was locked in the up position and would not release. He had to replace the switch. However, the manual switch that would have allowed the lift to lower slowly with minimal pressure on the lift arms was functional. He feels that it may have been a lack of training that the staff did not use it. He stated that emergency stop switches on the lift can go bad easily but all of them have the manual lowering switch. During interview on 9/4/19 at 4:21 p.m., with the Administrator present, Resident #1's Husband stated that he never instructed staff not to use the harness safety belt when using the lift to transfer his wife but he occasionally reminded staff not to place the belt directly over her PEG (feeding) tube site. During interview on 9/5/19 at 5:32 p.m., the Physician stated she had been chair-ridden for ten plus years and had very fragile bones that could have broken very easily without trauma. The Physician indicated he previously talked to the resident's husband about this. He stated the [MEDICAL CONDITION] contributed to her death but it was not a significant factor. 2. The MDS dated [DATE] documented Resident #9 had [DIAGNOSES REDACTED]. Resident #9 had severe cognitive impairments. Resident #9 required extensive assistance of staff with bed mobility and walking, utilized a walker and a wheelchair for mobility and had 1 fall without injury. The Occupational Therapy Plan of Care dated 8/14/19, documented Resident #9 suffered a left [MEDICAL CONDITION] and right humeral fracture on 6/10/19 (prior to admission) as a result of a fall. The Care Plan dated 6/19/19 identified Resident #9 had an actual fall with minor skin abrasion due to unsteady gait and poor safety awareness due to cognitive deficits, used antidepressant medication and required assistance with mobility due to weakness. The update on 9/6/19 directed staff to assist Resident #9 from the dining area when finished with meals and redirect attempts to stand up on own when in the wheelchair, assist to the dining area and assist with eating and then remove from the dining area to the nurse station after eating. The Morse Fall Scale dated 6/14/19, revealed Resident #9 had a score of 90 which indicated high risk for falls. On 9/6/19 at 2:50 p.m., Staff M (Dietary Aide) reported she observed Resident #9 in the dining room on two occasions without staff supervision when the falls occurred. Staff M stated it is a facility policy for nursing staff to supervise the dining room when occupied by residents. An Incident Report dated 9/2/19 at 9:59 a.m., completed by Staff K (Registered Nurse), documented Dietary staff reported Resident #9 on the floor in the dining room. The Staff found Resident #9 on her back. Resident #9 had adequate range of motion and no noted injuries but resident complained of a headache in the back of her head. An Incident Report dated 9/6/19 at 10:57 a.m., completed by Staff K, documented the Staff found Resident #9 sitting on the floor in the dining room with the wheelchair at the table. Resident #9 walked 10 feet independently, became weak, and went to the floor. Resident #9 struck her upper back and back of the head on the table. During interview on 9/6/19 at 3:25 p.m., Staff K stated she had the medication cart outside the dining room. Staff K reported she could not visualize the whole dining area from the cart. Staff K prepared medications and not always attentive to the dining room activity. She stated Staff M alerted her on 9/2 and 9/6 of Resident #9's falls. Staff K reported today she was down the hall administering medications when Staff M summoned her. Staff M stated it is difficult to supervise the dining room and pass medications in a timely manner as not all residents are in the dining room at the same time. During interview on 9/6/19 at 4:55 p.m., the Director of Nurses (DON) stated she would address the dining room supervision immediately. On 9/11/19, the DON presented a copy of the dining room supervision plan implemented on 9/7/19, which directed specific staff to supervise the dining room at specific times through the day. The plan directed the staff to remain in the dining room with residents still eating.

Based on clinical record review and staff interview, the facility failed to provide adequate supervision to prevent accidents for 3 of 7 residents sampled for nursing supervision (Residents #232, #44 and #78). The facility reported a census of 85 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment, dated 7/16/18, Resident #232 scored 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required the assistance of one for activities of daily living (ADL's) including bed mobility, transfers, ambulation, toilet use and dressing. The resident's [DIAGNOSES REDACTED]. A Fall Risk assessment dated [DATE] scored the resident at 80 indicating a high risk for falls. The Care Plan revised on 8/6/18 identified Resident #232 had impaired cognitive function related to periods of confusion and [DIAGNOSES REDACTED]. The interventions included to keep her safe during periods of extreme confusion and provide 1 to 1 with her as needed. The Care Plan revised on 5/2/18 identified the risk for falls due to a history of falls and cognitive loss. The interventions included use of a bed/chair alarm for safety as she got up without assistance, especially later in the day. The Progress Note dated 7/27/18 at 5:58 p.m. documented at 3:45 p.m. staff observed Resident #232 sitting on the floor beside her bed with her back facing the bedside stand. She stated she sat on the floor while getting out of bed and did not fall and did not hit her head. Resident #232 did not complain of pain or discomfort. The resident had an abrasion on her right lower back measuring 14 cm (centimeters) by 6 cm and a yellowing bruise with small purplish blotches within the bruised area with no firmness noted that measured 6 by 6 cm. A Fall SBAR (Situation, Background, Appearance and Response) form documented the resident last seen 1 hour prior to the fall but lacked any documentation about whether the alarm was on or functioning. The Progress Note dated 8/10/18 at 11:28 a.m. documented the resident fell that morning at the breakfast table, as witnessed by the dietary aide. The resident stood out of her wheelchair and tried to walk, tripped on the wheelchair pedal and fell on her buttock. A Fall SBAR form dated 8/10/18 described actions to prevent further falls as to put resident in recliner when she finished eating. The form lacked documentation of whether the alarm was on or functioning. The Progress Note dated 8/10/18 at 11:42 p.m. documented she was found slightly on her right side/back on the floor in front of her bathroom doorway around 5:50 p.m. Staff took her to the bathroom about 10 minutes before the incident. She could not say what she was trying to do when asked her how the fall occurred. Upon assessment, the resident complained of severe pain to the right hip and outward rotation of the right leg. Staff notified Hospice and they came and assessed the resident and directed to send the resident to the hospital. The Hospice nurse also helped the nurse gives the resident an as needed (PRN) [MEDICATION NAME] while this nurse tried to call the on-call doctor. Staff updated the resident's family of the event. The on-call doctor ordered to send the resident to the emergency room for evaluation and paramedics transported her at 7 p.m Th nurse called the hospital for an update and learned Resident #232 admitted for a right [MEDICAL CONDITION]. A History and Physical dated 8/10/18 documented Resident #232 fell at the nursing home and was not able to ambulate. The assessment included the resident had a right intertrochanteric femur (hip) fracture. The physician documented that surgery was in the resident's best interest because without it she would be unable to ambulate or mobilize. During an interview on 12/03/18 at 9:25 a.m. Staff A Dietary Aide stated she is hard of hearing but she can hear the alarms in the dining room. On 8/10/10 the resident was standing up during the meals trying to go on her own. Staff A stated during the morning meal the resident kept standing up. During the noon and the evening meal the resident continued to try and get up. At the evening meal the nurse took the resident back to her room. While she cleaned up at the kitchenette, another resident's husband told her Resident #232 was on the floor. She went to the resident's room and saw her laying on the floor. She did not hear the alarm sounding. She looked for someone to help. She said 1 CNA was giving a shower, the nurse was on break, and she could not find the other CNA. She went to another unit and asked for help. A CNA on the floor stated she could not leave the unit, so she went to the office and they paged for help. She said she asked the husband who told her the resident was on the floor if he heard the alarm, and he said no. During an interview on 12/3/18 at 2:39 p.m. Staff B Certified Nursing Assistant (CNA) stated she did not witness the fall 8/10/18 a.m., but heard about it afterward. She said she worked in a room giving a resident a shower so she did not hear the alarm. Resident #232 had been restless that day, constantly trying to get up. When she was like that they would try to keep her with someone. It would not be safe to leave her in her room in the recliner or the wheelchair, because she would just try and get up. During an interview on 12/4/18 at 11:00 a.m. Staff C CNA stated she worked on 8/10/18 and they would have checked at 2 p.m. to see the resident had the alarm on and it worked. Resident #232 tried to get up without assistance so they kept her where they could see her. She said the last time she saw the resident she sat at the dining room table. At the time of the fall, she gave another resident a whirlpool bath. She did not hear the alarm, but she wouldn't in the whirlpool room. During an interview on 12/4/18 at 11:12 a.m. Staff G Licensed Practical Nurse (LPN) stated she worked the evening shift on 8/10/18. The resident acted restless and just wanted to walk. She told her she couldn't walk by herself and sat Resident #232 by her until someone could walk with her. The resident continued to attempt to get up and she asked her if she wanted to go to the bathroom. A CNA (Staff H) came by and Staff G asked her to take Resident #232 to the bathroom. She gave another resident medications and then let the CNA know she was going on break. About 10 minutes later she got the call about the fall. She asked Staff H why after she asked her to take the resident to the bathroom she was on the floor by the bathroom door. The CNA told her the resident wanted to watch TV so she left her in the room. Staff G stated the CNA should not have left the resident in the room by herself when she had been making attempts to get up by herself, but the CNA was new and she didn't know. During an interview on 12/5/18 at 8:24 a.m. Staff K Clinical Coordinator stated if they didn't document whether the alarm was on and sounding (at the time of the incidents) she could not say if it was or not. It would be up to the caregiver to assure the alarm on and working. At the time of exit Staff H had not returned calls. 2. According to the quarterly MDS assessment dated [DATE], Resident #44 had a BIMS score of 8, indicating moderate cognitive and memory impairment. The MDS indicated Resident #44 required the assistance of two staff for bed mobility, transfers, and toilet use. The MDS listed he had [DIAGNOSES REDACTED]. The MDS recorded Resident #44 fell twice without injury since the previous assessment. Review of Resident #44's care plan recorded he had a long history of falls prior to admission to facility. He has fallen at home and at a previous nursing facility. He has also had falls and been lowered to the floor since admission. He is impulsive and does not always make safe choices. He had a high risk of falls related to [MEDICAL CONDITION], depression, anxiety, dementia, and diabetic [MEDICAL CONDITION]. The care plan listed the following interventions for staff to utilize: Ask and/or encourage him to use the bathroom and then get into recliner after meals, started on 1/21/18; Assist to the bathroom after all meals, started on 10/20/18; Assist with toilet use between 5:00 AM and 6:00 AM, started on 10/23/2018; Place a chair pad alarm to the wheelchair, started on 7/30/18; Educate staff to use a textured bedspread on his bed or one with non-slip materials, started on 10/14/17; Education given to overnight staff that his bed alarm needs to be plugged in when he is bed for the whole shift; Encourage him to sit in the lounge or by nurses desk for closer observation when awake, started on 9/14/17; Gripper socks on at bed and off in morning, started on 12/6/17; Keep the bed wheels locked; Keep the call light in reach when in his room; Low bed to the floor when resident is resting during the day and at night, started on 5/14/18; Make sure shoes are in good condition. A Progress note dated 7/30/18 documented Resident #44 observed on the floor at 9:00 AM in front of his bed with his back against a side rail and sitting on his buttocks. Resident #44 stated he did not hit his head; he put himself in bed and tried to get back out at the time of the fall. The nurse observed the resident's bed in a high position and his call light not within reach. Resident #44 also had a bed alarm, observed to be off. The nurse educated the Certified Nursing Assistants (CNA) on proper bed positioning and to make sure his call light is within reach. She also educated Resident #44 on the importance of asking staff for help. A Fall SBAR form for Resident #44 recorded the fall occurred on 7/30/18 at 9:00 AM. The resident stated he attempted to get out of bed without requesting help/assistance via the call light. Resident #44 was observed sitting on the floor bedside the bed with his back towards the bed. Resident #44 stated he did not hit his head and had no complaints of pain. When asked to describe what happened, the resident stated he tried to get out of bed and fell straight down onto his bottom; he did not hit his head. The resident's call light was not within reach. The form asked what could have been done to prevent this fall from happening, staff documented having his side rails down, his call light within reach, place his bed in a low position and have the resident's alarm on. During interview on 12/5/18 at 8:15 AM Staff M Registered Nurse Clinical Care Coordinator stated the resident had tried to self-transfer back to bed and that is when he fell . During interview on 12/05/18 at 8:42 AM, Staff L, LPN (Licensed Practical Nurse) stated Resident #44 told her he put himself back into bed after breaks and self-transferred back to his wheelchair. When she walked in to the room she noted the side rails were up, his bed as not in the lowest position and the alarm not sounding. She stated when staff got him up the morning they did not leave the side rails down, left the bed in the high position and did not turn on the alarm. Staff L believed the alarm is one that staff click on and off. Once the alarm is turned on and pressure is applied the alarm will sound. So if the alarm had been on, it would have sounded when the resident self-transferred to bed and again when he tried to get out of bed. 3. According to the MDS assessment dated [DATE], Resident #78 had severely impaired cognitive skills for daily decision-making. The MDS indicated he required the assistance of one staff member for transfers and toilet use. The resident had unsteady balance when moving from a seated to a standing position, moving on and off the toilet and during surface to surface transfers. The resident had [DIAGNOSES REDACTED]. Review of Resident #78's care plan, with a revision date of 8/24/18, revealed he had an increased risk of falls related to use of antidepressant and antipsychotic medications and history of falls prior to admission to the facility. Resident #78 appeared to have balance issues related to visual changes from dementia. He would stop when the color of the floor changed or with a difference in visible texture. He would focus and concentrate on the areas and at times felt the need to touch the area. The care plan listed the following interventions for staff to utilize: Change the bed pad alarm to a trigger call light, started on 8/28/18; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; Encourage the resident to sit in a recliner not the love seat when he is wearing windbreaker style pants, beginning 10/10/18; Ensure Resident #78 wire appropriate footwear; he preferred tennis shoes when walking; Keep his walkway clear to avoid stumbling, started on 9/10/18; Lead the resident to less populated areas when he wandered, started on 8/28/18; Staff re-arranged his room, moved his bed and added a motion sensor night light on 6/16/18; Staff set up a workspace so Resident #78 may stay busy and not wander into unfamiliar rooms and trip over items, started on 8/1/18; The resident needs activities that minimize the potential for falls while providing diversion and distraction drawing or music. An Incident/Accident report for Resident #78 dated 6/16/18 at 10:45 PM documented Resident #78 found standing in his room with blood over her face and hands. Bed alarm was on the bed but not properly attached. The Fall SBAR form dated 6/16/18 documented the resident found standing in his room, with blood all over his face and hands which appeared to be coming from the resident's nose at the bridge. Under the appearance section, staff was unable to respond appropriately and found him standing in his room while doing rounds. The form asked what was different this time that may have led to the fall? Staff listed alarm did not function properly and lighting as not appropriate for the room. A Progress Note dated 6/17/18 at 8:33 AM recorded Resident #78 fell in his room at the start of the shift. The evening nurse was with the resident. Staff called his doctor, who gave orders to send the resident to the emergency room to be evaluated and treated for [REDACTED]. Resident #78 had dementia and staff needed to anticipate his needs. An Emergency Department Physician note dated 6/16/18 indicated Resident #78 sustained a nasal bone fracture following a fall at the nursing home. On 12/5/18 at 10:00 AM the DON stated they removed furniture from his room and re-arranged it as part of their root-cause analysis. They also added a wall light. When asked the about the alarm not functioning she stated it was there to alert staff of him moving. He liked to fidget with things and could have moved it (information not relayed on the care plan).

Based on clinical record review, facility policy review and staff interviews, the facility failed to provide adequate nursing supervision to prevent accidents for 1 of 4 current residents sampled (Resident #1). The facility identified a census of 90 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented the pertinent [DIAGNOSES REDACTED].#1. The same MDS documented the resident admitted to the facility on [DATE] for Medicare A skilled nursing services and had a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. Resident #1 required extensive assistance of one staff for completion of transfers, ambulation, and toileting. Resident #1 had limited functional range of motion (ROM) of one leg and assessed the resident as unsteady and only able to stabilize with staff assistance to complete movement from a seated to a standing position, walking or moving to and from the toilet, and for surface-to-surface transfers. The assessment revealed Resident #1 used a walker and wheelchair for mobility. The MDS also documented the resident had a fracture related to a fall in the 6 months prior to admission. The Admission Care Plan dated 9/7/16 identified the resident only able to bear partial weight on the right leg and required 1 staff assistance for completion of transfer/s using his/her front wheeled walker. The care plan identified staff to assist Resident #1 with toileting as s/he directs; and provide resident care per facility protocol. The care plan revealed Resident #1 scored 75 on the Morse Fall Score, which indicated he/she at high risk for falls. The Daily Skilled Nurses Notes dated 9/13/16 at 4:30 PM documented the resident had 4+ (severe) pitting edema of both ankles and lower legs. The 6:30 PM entry documented the physician ordered the resident's blood pressure taken 2 times a day (BID) for 2 weeks and to fax the results to the physician weekly. The Incident/Accident Report dated 9/13/16 at 5 p.m., revealed Resident #1 insisted to walk to the bathroom with his/her walker. A certified nurse aide (CNA) walked with him/her to the bathroom. Resident #1 unable to void with CNA present, and CNA stepped (away) for privacy. When the CNA returned, he/she brought w/c (wheelchair) to pull up behind him/her when resident fell down. The assessment revealed Resident #1's blood pressure of 140/62 after the fall with right hip/back/leg pain. The incident report revealed the resident's [DIAGNOSES REDACTED]. The Daily Skilled Nurses Notes entry dated 9/13/16 at 11:00 p.m. documented the resident fell in the bathroom at 5:00 p.m., and observed in the corner with his/her head resting against the wall and most of his/her weight positioned on the right hip. The certified nursing assistant (CNA) stated the resident insisted on walking to the bathroom using a walker. The resident stood to void but could not do so with the CNA present. The CNA then stood right outside the bathroom door. The resident yelled when finished in the bathroom. The CNA brought in the resident's wheelchair to pull up behind the resident but the resident lost balance and fell . The resident could not stand any movement of the area. The resident transferred to the emergency room and subsequently admitted to the hospital. The Hospital consultation report & History and Physical dated 9/14/16 revealed the physician had been familiar with Resident #1 after his/her basicevical fracture of the right hip; which occurred on 8/16/16. At that time Resident #1 had surgical repair for his/her right intertrochanteric fracture of the hip and had been in rehab at the nursing home. The consultation report revealed he/she was admitted on [DATE] after the Resident #1 slipped and fell directly onto his/her hip, suffering a comminuted fracture of the femoral shaft (thighbone). The previous intertrochanteric fracture fixation remained intact; however he/she broke through the shaft (thighbone) from the mid portions of the nail distally. The physical examination and x-rays showed a comminuted fracture of the right femoral shaft (thighbone). Resident #1 underwent surgery and tolerate the procedure well. Review of the Fall SBAR dated 9/13/16 revealed the resident may have gotten dizzy and had an unsteady gait. The CNA brought in the wheelchair and the resident had been standing by the sink. The CNA brings the wheelchair up behind and the resident falls to the floor. Staff B's statement dated 9/13/16 revealed she walked into Resident #1's room to talk with Staff A. Staff A had been standing outside the bathroom while the resident was going to the bathroom. Staff B reported Staff A continued to check in with the resident. Staff B documented when Resident #1 was all done, Staff A started to put the wheelchair into the bathroom for Resident #1 to sit in. Staff B documented Resident#1 had turned and walked to sit down but fell on his/her right side and hit his/her head on the wall. Staff B documented she went to get the nurse and this occurred around 5 p.m. The Administrator reported Staff B no longer an employed by the facility. During interview on 4/20/17 at 2:40 p.m. Staff A CNA, stated before supper, Resident #1 wanted to go to the bathroom. At this time the resident sat in a recliner is his/her room. Staff A told the resident she would be right back; when she returned the resident had already self-transferred to the wheelchair. Staff A stated the resident refused to allow use of a gait belt and the resident ambulated independently into the bathroom after she placed the wheelchair where s/he could grab the bar. Staff A stated she stood outside the bathroom door per the resident's request but peeked in the door frequently. When the resident indicated s/he being done in the bathroom she pushed the wheelchair into the bathroom and place it behind the resident so s/he could turn and sit. Resident #1 fell when turning to sit in the chair. Staff A stated it is the facility's policy to use a gait belt during transfer if the resident required assistance. She stated she did not know if she told anyone at the time of the fall or investigation that the resident refused the gait belt. Staff A receive disciplinary action for failure to use the gait belt. The Employee Counseling/Coaching Record (final warning) dated 9/22/16 documented Staff A disciplined for the following concerns: 1) transferring a resident who required assistance with transfer and ambulation without the use of a gait belt. 2) failure to follow a resident's care plan of care on assistance level and not reviewing activities of daily living on the care plan or asking the supervising nurse on any changes. 3) left a resident alone or within reaching distance that required contact assistance with transfers and ambulation. During interview on 4/14/17 at 1:39 p.m., the Director of Nursing (DON) stated if the resident could not void with the CNA present the CNA should have encouraged the resident to sit on the toilet to void or use the urinal while seated in the chair or bed. The DON stated all CNA's were re-educated to the gait belt policy at the monthly CNA meeting on 9/15/16 because of this incident. The investigation identified the facility corrected the noncompliance prior to the arrival of this investigation and was in substantial compliance on 9/15/16.

Based on observation, record review, interviews with staff and resident, the facility failed to plan for and direct nursing care and services to ensure one (1) of (5) residents received adequate supervision from hazards. The facility staff failed to safely transfer Resident #2 according to his/her care plan who subsequently sustained a spiral fracture to the right lower leg which required surgical intervention. The facility reported a census of 88 residents. Findings include: According to the MDS (Minimum Data Set) assessment, with a reference date of 11/2/11, Resident #2 had [DIAGNOSES REDACTED]. The assessment documented the resident had a score of 12 for the Brief Interview for Mental Status, indicating cognitive impairment (a BIMS score of 13-15 indicates intact cognition). The assessment documented Resident #2 did not walk and required extensive assistance from 2+ staff members for transfers. The resident's care plan dated 8/25/11 directed staff to transfer the resident using a Hoyer lift (mechanical lift) and 2 persons. A handwritten entry dated 11/8/11 documented staff may use slide board with 2 assist for transfers after being trained by therapy staff. The CNA Worksheet dated 11/16/11 issued to Staff L, Certified Nursing Assistant (CNA), agency staff, directed staff to use a Hoyer lift and 2 persons to transfer the resident. A Physical Therapy Daily Treatment Note dated 11/16/11 documented the physical therapy assistant (PTA) had walked into the resident's room at 3:00 p.m. that day. The note indicated the resident immediately informed the PTA that his/her right leg had been twisted earlier that day and it hurt. Upon observation, the PTA noted the resident's right foot was externally rotated so that the outer food laid on the bed while the rest of the resident's leg was not externally rotated. The resident when questioned by the PTA, stated his/her leg was twisted during a transfer from the bed to the wheelchair after lunch. The PTA asked the resident if staff had used the slideboard to transfer him/her to which the resident replied, "No." The PTA asked the resident if staff had used the Hoyer lift to transfer him/her; the resident stated that staff had used a gait belt to transfer him/her. When the PTA asked if they tried to stand him/her, he/she said, "No, they lifted me, scooped me up like a baby." The resident further explained one aide had transferred him/her. The resident indicated he/she had pain, near the right ankle, when that area was touched/palpated. The PTA documented that when she informed the resident's nurse of the unusual findings, the nurse assessed the resident's leg. A nurse's note dated 11/16/11 at 3:30 p.m. documented Resident #2 had complained of right ankle pain. The note indicated the resident had 6 to 8 inches of bruising, with edema, on the right lower leg. The nurse documented she gave the resident Lortab (pain medication), one 5/325 mg (milligram) tablet, and notified the resident's primary care physician of the assessment findings. The nurse received an order to transfer Resident #2 to a local emergency room for an x-ray. The Emergency Department physician's notes dated 11/16/11 documented Resident #2 had sustained an acute right spiral distal tibia fracture as well as an acute right proximal fibula fracture which required surgical repair. Observation on 12/2/11 at 9:16 a.m. revealed Resident #2 had a bandage on the right knee and 9 stitches noted on Resident #2's right ankle. The right foot appeared externally rotated. Both legs were elevated. In an interview on 12/2/11 at 2:51 p.m., Staff K, CNA, stated she and Staff L, CNA, had entered the resident's room on 11/6/11. Staff K said Resident #2 had wheeled him/her(self) to the side of the bed. Resident #2 had stated, "I need to go to the bathroom." Staff K said Staff L had walked in front of the resident's wheelchair facing the resident, and applied a gait belt on the resident. Staff K said she reached from behind the wheelchair to lock the brakes. Staff K said she then turned around to grab the slideboard which was positioned against the wall at the end of the bed, and by the time she turned around to get it, Staff L had picked the resident up by the gait belt and transferred the resident to the bed. Staff K said she heard the resident yell out, " My foot!" Staff K said she turned around and saw the resident's right foot externally rotated to the right, pointing towards the head of the bed. Staff K said she they quickly placed the resident's legs into bed. Staff K said she noticed the resident's foot "drop" towards the right- more so than usual. Staff K said she asked the resident if he/she had pain and the resident denied having pain at the time. Staff K said Staff L placed the resident on the bedpan while she went to get the nurse. Staff K said Staff D, Licensed Practical Nurse, went to the resident's room and did range of motion on the resident's right foot. The resident denied pain at that time. Staff K indicated the only transfer she performed with Staff L that day involved Resident #2. Staff K said Staff L transferred the resident on her own. Staff K said Resident #2 had ted hose on his/her right leg. After the transfer, the resident's right leg looked like it had something sticking up out of it. Staff K said she did not see bone, but it felt "like a hard lump." Staff K said she had been trained to use the slide board 2 weeks prior by physical therapy. Staff K said prior to using the slide board to transfer Resident #2, they used a Hoyer lift to do so. Staff K said the facility had aide sheets that each aide carried with them that told how to care for their residents during the shift. Staff K said Staff L had received a sheet as well. In an interview on 12/9/11 at 11:54 a.m., Staff L (a staffing agency CNA) stated she and Staff K had put a gait belt on Resident #2, and with Staff K standing on one side of the resident, and she on the other side, they transferred the resident to the bed. Staff L said they did not use a slideboard or a Hoyer lift. In an interview on 12/7/11 at 9:32 a.m., Staff D, LPN, stated Staff K, CNA, had called her to Resident #2's room because his/her foot looked different. Staff D said when she entered the room, Resident #2 lay in bed with a small blanket over him/her. Staff D said the resident had ted hose on, and she noted the resident's right foot to be rotated outward which was usual when the resident was lying in bed. Staff D said she asked the resident if he/she could move the right foot. Staff D said she did active range of motion and passive range of motion and had no indications of injury. Staff D said the resident did not voice any pain or discomfort and she did not observe any swelling or edema. Staff D said because of no indication of pain or problem observed she did not remove the resident's Ted hose or report her assessment findings to the oncoming nursing staff. In an interview on 12/2/11 at 11:52 a.m., the Assistant Administrator stated on 11/16/11, she received a call from Staff H, LPN, at approximately 3:30 p.m. to come to the first floor to assess why therapy refused to conduct their therapy program for Resident #2. The Assistant Administrator said when she entered the room, the resident lay in bed and a nurse removed the resident's ted hose from the right leg. The Assistant Administrator said she noted the resident's right foot externally rotated so that the resident's entire lateral foot touched the bed. The Assistant Administrator said she became concerned as the resident had a history of [REDACTED]. The Assistant Administrator said she visually assessed the resident's right lower leg and noted the lower leg toward the ankle appeared edematous and light blue in color compared to the left leg. The Assistant Administrator indicated the resident could move his/her foot back and forth and denied pain to the leg except when it was touched. The Assistant Administrator asked the resident how this occurred, and the resident said the little aide, Staff L, had picked him/her up, like a baby. The Assistant Administrator said she notified the Staffing Agency of the incident. In an interview on 12/14/11 at 9:41 a.m., Resident #2 said a girl, who did not work there, broke his/her ankle when she tried to carry me from the bed to the chair. Resident #2 said he/she told her not to do it, but the girl said she did it all the time. When the aide picked her up, he/she told the aide, it hurt. Resident #2 said he/she spent 2 weeks in the hospital (after the incident). In an interview on 12/14/11 at 9:37 a.m., the Director of Nursing said the facility offered new agency CNAs training and orientation to the floors they were assigned to, and that all the facility CNAs were to be trained to use the slideboard when transferring Resident #2. The CNAs were also trained to use the Hoyer lift with an assist of 2 staff if they were uncomfortable transferring Resident #2 with the slideboard.

Based on record review and interviews, the facility failed to plan timely interventions and services for one of five residents. Resident #4 ' s excessive does drug regimen presented adverse drug consequences which indicated the dose should be reduced or discontinued. The facility reported a census of 84 residents. Findings include: Prior to admission to the nursing home, Resident #4 had been in the hospital and according to a mental health consultation report completed on [DATE], the psychiatric physician reviewed the resident ' s medications and elected to add 2 milligrams (mg) of [MEDICATION NAME] medication, 4 times a day. The consultation report documented Resident #4 had been taking 10 mg of [MEDICATION NAME] (4 times a day); 300 mg [MEDICATION NAME] (in morning ) and 450 mg (at night); 100 mg of [MEDICATION NAME] at night ; 10 mg [MEDICATION NAME] sublingual (twice a day); and 60 mg of [MEDICATION NAME] (twice a day). The physician noted Resident #4 on a fair amount of antipsychotics medications and indicated they could taper the medications if the resident became too sedated. The physician documented she had informed the nursing home staff she will follow up on the resident the following day and might make some further alterations to the medications. The hospital Discharge Summary dated [DATE] documented during Resident #4's stay, he/she did well. The physician documented some of psychiatric medications were increased and the resident quiet down and unfortunately the resident had been sedated. The physician documented she needed to see the resident in the physician ' s office in a couple of weeks or sooner with any problems and suggested a psychiatry - follow up. The primary [DIAGNOSES REDACTED]. A Dismissal/Interagency Instruction Sheet from the hospital dated [DATE] documented Resident #4's mental health status as confused and forgetful. The sheet did not indicate Resident #4 as unresponsive. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #4 had been admitted to the nursing home on [DATE]. The MDS assessment identified the resident demonstrated unclear speech with a limited ability to express ideas and understand verbal communication. The MDS determined Resident #4 exhibit long and short term memory problems and severely impaired cognitive skills for daily decision making. The MDS assessment revealed Resident #4 showed a continuous altered level of consciousness and psychomotor [MEDICAL CONDITION] (decreased level of activity such as sluggishness). The MDS documented Resident #4 required total staff assistance with all activities of daily living (ADL's). Resident #4's [DIAGNOSES REDACTED]. Resident #4 received antipsychotic and anti-anxiety medication. The nursing home Admission Care Plan dated [DATE] identified Resident #4 had recently been confused and forgetful. The care plan intervention are as follows: a). The care plan interventions for [MEDICAL CONDITION] called staff to assess the resident for impact of polypharmacy (use of multiple medications) and psychoactive meds. Staff documented the resident had changes in [MEDICAL CONDITION] treatment, which maybe causing acute [MEDICAL CONDITION] and staff would continue to monitor and attempt reduction. b). The cognitive loss section of the care plan describe Resident #4 upon admission as very sleepy and unable to keep his/her eyes open. Staff updated the care plan on [DATE] and documented Resident #4 had been very lethargic and unresponsive at times. c). The mood state section of the care plan included an intervention to administer medications as ordered and to work with resident on reduction of [MEDICAL CONDITION] medications. d).The nutritional status section of the care plan included intervention report problems. e). The [MEDICAL CONDITION] drug use section called for staff to monitor target behaviors and side effects per [MEDICAL CONDITION] flow sheets, and called for gradual dose reduction, and refer to social services as needed. The intervention also directed staff to notify the physician and work on attempting to decrease [MEDICAL CONDITION] medications if appropriate. The name of the resident ' s psychiatric physician's assistant had been written on the care plan. On [DATE] the care plan update identified Resident #4 had been unresponsive; continue to monitor, this was a change in comparison to a prior discharge ([DATE]). An undated Psychosocial Need form documented Resident #4 had psychosocial need related to changing medical condition and altered mental status. Resident #4 [DIAGNOSES REDACTED]. Planned for Resident #4 to stay long term. The Psychiatric PA was following and reviewing [MEDICAL CONDITION] medications. The Medication Sheets dated [DATE] documented Resident #4 received the following [MEDICAL CONDITION] (work in the central nervous system) medications: a. [MEDICATION NAME] 10 mg orally 4 times a day. b. [MEDICATION NAME] 2 mg orally 4 times a day. c. [MEDICATION NAME] 10 mg sublingual 2 times a day. d. [MEDICATION NAME] 60 mg orally 2 times a day. e. [MEDICATION NAME] 100 mg orally at bedtime. f. [MEDICATION NAME] 300 mg orally in the morning, and 450 mg at bedtime. The Progress Notes by the Social Worker documented on [DATE] Resident #4 exhibited sleepiness and would say a few words, but mostly non responsive to his/her environment. They were unable to do paperwork due to lack of alertness. The Daily Skilled Notes documented on [DATE] at 7:00 p.m. Resident #4 didn't wake up after numerous attempts to wake him/her etc. The notes identified the resident slept throughout the shift. PACE (Program of All inclusive Care for the Elderly) Progress Notes dated [DATE] documented performed a joint visit with the Social Worker to settle Resident #4 into the facility. Resident #4 was very lethargic, responded to a few questions, then asked to be left alone so he/she could sleep. Conference with 2 staff nurses. The social worker Progress Notes dated [DATE] documented staff again attempted to do paperwork and unable due to the same cognitive status as the previous day. The Social Worker tried to get Resident #4 to wake up a little, but he/she kept eyes closed and mumbled. The Daily Skilled Notes documented on [DATE] Resident #4 alert at times, disoriented times 3, yells out for help and to hurry up. The Daily Skilled Notes documented on [DATE] Resident #4 disoriented times 3 and yells help me several times. The notes identified the resident would not verbally respond to questions. The PACE nurse notified of 9 pound weight loss since admit. The Daily Skilled Notes documented the following: On [DATE] Resident #4 drowsy, very lethargic, disoriented times 3(person/place & time). The note describe the resident unable to stay awake when talked to, speech unclear and eats only bites for breakfast and drinks 600 cc's. The notes revealed the doctor's office called regarding insulin. Regarding lethargy no new orders due to psych medication. The report documented the resident saying "God help me", and a call placed to PACE to evaluate. Staff documented Resident #4 had [MEDICATION NAME] and [MEDICATION NAME] at 4:00 p.m. so he/she continued to sleep. The notes revealed staff informed PACE this did not help the resident to eat. The notes described Resident #4 made no eye contact, opened mouth very little, occasionally moved arms. The notes identified the resident did not participate in conversations, and repeated "Help me, help me" from time to time. The staff documented the PACE nurse called with order for pureed diet, the physician wanted it due to Resident #4's lethargy. The clinical record lacked any substantial measure to address the resident ' s lethargy or adjust the resident ' s psychiatric medications. A Physician's Telephone Order dated [DATE] directed to give the scheduled insulin then and give the 5:00 p.m. dose at 7:00 p.m.. Have Resident #4 eat at 6:00 p.m. If he/she did not eat supper page the physician. Another Physician's Telephone Order dated [DATE] directed low concentrated sweets, pureed diet. On [DATE] at 12:30 a.m., the skilled notes identified staff attempted to arouse Resident #4 and he/she kept eyes closed. At 2:35 p.m. Resident #4 lethargic and did not get out of bed today. Resident #4 repeatedly called out "Help me". Nurse from hospice looked over Resident #4 and notified the physician. New orders for a urine analysis and [MEDICATION NAME] level. PACE Progress Notes documented on [DATE] at 12:30 p.m. Resident #4 was fed lunch, he/she was lethargic. He/she ate approximately 25% (facility documented 0 food) and was able to sip water from a straw, drinking an 8 ounce glass. Resident #4 cooperated, but did not open his/her eyes. He/she did squeeze the nurse ' s hand with a weak grasp. The RN spoke to a nurse from the facility who stated Resident #4 was very lethargic and appeared to have declined rapidly. The nurse stated when Resident #4 resided in the facility before and had a critically high [MEDICATION NAME] level he/she would be very lethargic. The PACE Physician updated and received orders for [MEDICATION NAME] level and UA and culture and sensitivity. PACE Progress Notes documented on [DATE] a skilled nurse drew a [MEDICATION NAME] level and obtained a urine analysis. PACE Progress Notes documented on [DATE] at 10:00 a.m. Resident #4 slept peacefully, woke to voice and touch, did not open eyes, answered yes or no when questioned, stating no to pain. Reviewed lab results, [MEDICATION NAME] level high, and UA negative. Phone call made to PACE Physician, update on lab values, no changes made, no new orders, instructed to inform PACE on [MEDICATION NAME] level and contact Resident #4's Psych Physician with levels. The Daily Skilled Notes dated [DATE] at 1:30 a.m. revealed Resident #4 non compliant with opening eyes. The staff described tremors in both hands and some rigidity in left arm. At 8:00 a.m. the resident awoke to verbal stimuli and staff documented very sleepy and lethargic. The UA and [MEDICATION NAME] results received from lab with hospice nurse reviewed lab work with no new orders. At 2:00 p.m. friends visited. PACE Progress Notes documented on [DATE] at 9:56 p.m. received a phone call from staff at the facility who called a condition report. The staff member stated she asked Resident #4 how he/she felt, and the resident responded he/she felt better. The staff member stated the UA and [MEDICATION NAME] level had been drawn and were essentially normal. The staff member requested the PACE center check on the resident the next day and denied the need for a nursing visit at the time. The Daily Skilled Notes from [DATE] described the resident as lethargic. At 7:00 a.m. the resident opens eyes to verbal stimuli, knows nurse by name. The notes revealed the resident remained lethargic; OT (Occupational Therapy) and PT (Physical Therapy) tried to work with resident and unable to due to resident's lethargy. The notes revealed the resident remained lethargic and held food in his/her mouth and swallowed with verbal commands. At 10:00 p.m. the note described lethargy continued. The social worker Progress Note on [DATE] identified Resident #4 remained mostly unresponsive with eyes closed. He/she would answer briefly with a yes at times. A fax to the physician's assistant (PA) dated [DATE] documented for review of medications per request due to resident lethargy, sleepy, etc. per nursing telephone report. The fax returned with orders to decrease [MEDICATION NAME] to 450 mg at bedtime. Need to check kidney function, BUN, Creatinine and GFR, it seems kidney function might be compromised. During an interview on [DATE] at 10:30 a.m. Staff C, Registered Nurse (RN) stated they tried to figure out why Resident #4 was so lethargic. Staff C stated Resident #4 walked out of the facility in [DATE] and went home. Regarding the fax dated [DATE] to the PA, Staff C stated the PA requested the medication sheets. Staff C stated she sent the cover sheet and the med sheets. Staff C stated Staff B, RN, the nurse on duty that day would have called the report to the PA. The clinical record lacked any documentation of a phone report to the PA. During an interview on [DATE] at 10:50 a.m. after looking at the nurse's notes for [DATE], Staff B stated she sent the [MEDICATION NAME] level results to the PA, she did not call a report to him. The social worker Progress Notes dated [DATE] identified she visited with Resident #4, but he/she did not respond at all. Discussed with the PACE Social Worker, and she thought the plan included trying to gradually reduce some of the [MEDICAL CONDITION] and would discuss his/her condition with the PACE staff. The social worker documented psychosocial need identified related to altered mental state and declining physical condition. The Daily Skilled Notes for [DATE] described Resident #4 as disoriented times 3, lethargic, with a poor appetite. The resident did not move extremities independently, stiff with poor mobility, responds with one word answers slowly. The staff assessed resident mucous membranes as dry. According to the Assessment Reference Date (ARD) report dated [DATE], staff describe Resident #4 as lethargic, dependent for care, poor oral intakes, and unable to verbalize needs. The report identified when Resident #4 ' s eyes were open, they were fixed. The clinical record lacked documentation any of the practitioner's was notified of all of these signs and symptoms listed. On [DATE] at 7:00 a.m. the Daily Skilled notes revealed Resident #4 called out "Momma", and the physician's office had been informed Resident #4 experienced a 13 pound weight loss and would start on sugar free health shakes (6 ounces 3 times a day). The notes described the Resident #4 remained lethargic all shift, and continue to call out, when asked what he/she needed, did not answer, but continued to call out. The notes revealed both PT and OT services would be discontinued due to altered status. The note described the resident stared into space with his/her eyes open. The social worker documented on [DATE] that nursing reported Resident #4 started antibiotic therapy for a UTI and would monitor for increased alertness as UTI resolved. PACE Progress Notes documented on [DATE] at 4:30 p.m. an RN and an ARNP to visit Resident #4 at the facility. Resident #4 laid back in the recliner with his/her feet up... Resident #4 had to be fed, the physician ordered a pureed diet for him/her and he/she only ate about 25% of that.Resident #4's record contained no dictation from the ARNP. The Daily Skilled Notes for [DATE] revealed Resident # ' 3 ' s mucous membranes were dry. The staff documented the resident called out at times when asked what he/she needed just stared. On [DATE] awake, eyes open, responds slowly to questions. Called out at times, had fixed gaze. When asked what he/she needed just mumbled, unable to understand. Staff documented he/she had been up in his/her recliner, no verbal conversation, did not move extremities, stared with flat effect look on face with eyes half open. The Nurse's Notes documented: On [DATE] at 4:30 p.m. Resident #4 did not open eyes when talked to, could see blinking and slept most of the shift. On [DATE] at 2:00 p.m. up in recliner most of the shift and called out at times, when asked what he/she needed would not answer. Resident #4's eyes were partially open and stared with a flat effect. Resident #4 ate poorly, holding pureed food in his/her mouth, drank fluids well. The note described Resident #4 acted very lethargic. On [DATE] at 11:45 a.m. staff left a message with the PA's phone nurse regarding the PA actually visiting the facility to assess Resident #4 and review current medication regime to determine if medications could be decreased to assist in decreased lethargy and inability to participate in ADL's. At 2:15 p.m. the PA's office requested concerns. Advised by a fax nursing concerns included lethargy, total dependence with ADL's to include feeding, poor oral intake, inability to verbalize needs, and calls out for help. These were all areas of concern as Resident #4 was limited assist with ADL's and ambulation with a wheeled walker when previously discharged from the facility in [DATE]. In addition faxed current list of medications and requested medication regime be reviewed, specifically scheduled [MEDICATION NAME]. New orders received from the PA to decrease [MEDICATION NAME] to 5 mg 3 times a day, discontinue [MEDICATION NAME], don't give more [MEDICATION NAME] tonight, and hold the [MEDICATION NAME]. Start [MEDICATION NAME] 0.5 mg 2 times a day tonight. The social work Progress Notes dated [DATE] revealed the social worker visited with the MDS RN and discussed Resident #4's condition, because of the large amount of antipsychotics and [MEDICAL CONDITION] medications, which appeared to be sedating him/her and affecting him/her negatively. The RN would send a facsimile to the Psychiatric Physician's Assistant, and requested he come to the facility and assess Resident #4. A facsimile (fax) dated [DATE] notified the Physician's assistant Resident #4 had been very lethargic since his/her admission to the facility. Resident #4 previously resided at the facility but discharged to home [DATE]. At that time Resident #4 required limited assistance with activities of daily living (ADL's) and discharged home ambulating with a walker. Resident #4 now required total assistance with all ADL's, a Hoyer lift for transfers. Staff fed Resident #4 and his/her oral intakes were poor. Resident #4 could not verbalize his/her needs, though had said "water", "help" and "Mommy". Resident #4's eyes usually remained closed, but when open he/she had a fixed gaze and didn't seem to follow movements. Looking through Resident #4's history since discharge from the facility ([DATE]) it was unclear exactly what cause the resident to have such an increase in [MEDICAL CONDITION] medications, specifically [MEDICATION NAME]. The PACE Social Worker stated Resident #4 called out for help and stated wanting to hurt him/herself. Resident #4 also demonstrated more confusion, belligerence, and threw him/her(self) on the floor (at another facility). Please review medication regimen and advise how to proceed. A Physician's Telephone Order dated [DATE] at 5:45 p.m. regarding increased lethargy and unresponsiveness, decrease [MEDICATION NAME] to 5 mg 3 times a day, discontinue [MEDICATION NAME], don't give more [MEDICATION NAME] tonight, hold [MEDICATION NAME] 0.5 mg 2 times a day and start tonight. A fax dated [DATE] documented the Physician's Assistant (PA) would like to know how Resident #4 responded to the medication changes done the previous day. The Nurse's Notes dated [DATE] at 1:30 p.m. documented the facility received a request from the PA for an update on Resident #4. The facility advised Resident #4 continued to be very lethargic and unresponsive, though responded slightly by opening eyes in response to sternal robe. Resident #4 took his/her 8:00 a.m. medications in addition to 275 cc's fluid, and bites of breakfast. Unable to administer noon medications. Resident #4 would not take nor would he/she eat/drink at lunch. He/she let food and fluids run out of his/her mouth. Resident #4 continued to be unresponsive. At 12:00 p.m. the facility informed the Physician Resident #4 would not eat lunch and let food and fluids run out of mouth. At 12:00 p.m. and 1:00 p.m. staff held medications due to not swallowing. At 2:00 p.m. orders received from the Physician office for lab work, and to contact the PA because he handled the medications. At 4:00 p.m. 3 nurses tried to arouse Resident #4 several times. They used a sternal rub, cold cloth applied to forehead, and moving him/her around performing ROM to both upper extremities. Resident #4 was very stiff and when allowed to relax, upper extremities were cogwheeling (increased resistance of muscle), stiff and shaking. Resident #4 could not follow any command or respond to verbal or physical stimuli. Because of Resident #4's condition, the facility received an order to hold all medications. The facility responded with a return fax dated [DATE]. Resident #4 continued very lethargic and unresponsive. He/she did respond slightly to sternal rub by opening his/her eyes, though eyes remained fixed. Nursing reported Resident #4 able to take his/her 8:00 a.m. medications in addition to 275 cc's of fluid and only bites of breakfast. They were unable to administer his/her noon medications because Resident #4 would not take with applesauce or drink. Resident #4 had no intake at lunch, letting food and fluid run out of mouth. Continued to be unresponsive and would not eat or drink. Nursing provided an update to the Physician, and she ordered some lab work, but would like the PA to address the medication changes. PACE Progress Notes documented: On [DATE] revealed the Resident #4 was unresponsive, not able to swallow, take meds and had saliva running from his/her mouth. The documented revealed wants an order to transfer to hospital. The staff documented they would inform the PACE nurse who would contact her. The document revealed the PACE nurse did not want Resident #4 transferred to the hospital. The staff then requested the PACE nurse evaluate the resident at the nursing home. On [DATE] an RN visited Resident #4 at the facility. Many friends gathered. Resident #4 was unresponsive. Resident #4's friend wondered why this happened. The RN told her that even Resident #4's nurses and medical staff did not completely understand Resident #4. PACE Progress Notes documented on [DATE], 2 PACE nurses went to the facility to assess Resident #4. Resident #4 laid in bed unresponsive. All medicines held including insulin except for comfort meds per the PACE Physician. A fax dated [DATE] (no time) revealed ok to follow direction of PACE physician. The order revealed to start comfort measures and there was nothing that could be done from psychiatric standpoint in the resident ' s condition. Interviews: During an interview on [DATE] at 2:11 p.m. Staff I, PACE program Director stated PACE collaborated with facilities in providing care. Staff I stated their ARNP saw Resident #4 on two occasions. Staff I stated a psychiatric physician's assistant (PA) was in charge of Resident #4's psychiatric medications. (The record lacked any documentation the PACE staff notified the psychiatric PA of Resident #4's condition). Staff I stated they felt Resident #4 just gave up. During a subsequent interview on [DATE] at 8:15 a.m. Staff I stated they have learned from this case and see there are things they can do differently. During an interview on [DATE] at 8:46 a.m. Staff J, PACE Social Worker stated when she first saw Resident #4 at the facility she could really see a change. Staff J stated Resident #4 responded a little to her. Staff J held Resident #4's hand and he/she did open his/her eyes at first. Staff J stated she thought the plan was to decrease Resident #4's psychoactive medications. During an interview on [DATE] at 8:55 a.m. Staff K, PACE Personal Care Assistant (PCA) stated she knew Resident #4 from when he/she resided at home. Staff K saw Resident #4 the first week he/she was at the facility. Resident #4 was very lethargic. Resident #4 would call out "Help me, help me, help me". Staff K stated Resident #4 wasn't eating much. Staff K went to the facility and fed Resident #4 some pudding. Staff K stated she put her finger on the end of the straw to give him/her fluids a small amount at a time. Staff K stated Resident #4 did open his/her eyes, but did not focus, and then he/she got to the point where he/she did not open his/her eyes. During an interview on [DATE] at 9:07 a.m. Staff L, PACE RN stated when she made the visit with the ARNP ([DATE]), Resident #4 did not respond to them. Staff L stated she did not notify the physician. The 7-Day Observation and Monitoring Forms dated [DATE] to [DATE] and [DATE] to [DATE] documented Resident #4 demonstrated lethargy every day. In addition the Resident Meal Intake Sheet documented Resident #4 consumed the following: On [DATE] Supper 0 food, 0 fluid. On [DATE] Breakfast, 25% food/240 cc's fluid. dinner, bites food/200 cc's fluid; and supper 0 food/200 cc's fluid. On [DATE] Breakfast, bites food/400 cc's fluid; dinner, 0 food/240 cc's fluid; and supper, 0 food/0 fluid. On [DATE] Breakfast, bites food/600 cc's fluid; dinner, 0 food/0 fluids; and supper, nothing marked. On [DATE] Breakfast, nothing marked; dinner, 0 food/240 cc's fluid; and supper, 0 food/0 fluid. On [DATE] Breakfast, nothing marked; dinner, 0 food/0 fluid; and supper, bites food/sips fluid. On [DATE] Breakfast, 25% food/600 cc's fluid; dinner, 50% food/ 480 cc's fluid ; and supper, 100% food/320 cc's fluid. On [DATE] Breakfast, 0 food/0 fluid; dinner, nothing marked; and supper, bites food/340 cc's fluid. On [DATE] Breakfast, 0 food/sips fluid; dinner, bites food/100 cc's fluid ; and supper, 25% food/ 350 cc's fluid. On [DATE] Breakfast, 75% food/660 cc's fluid; dinner, bites food/ 240 cc's fluid; supper, 25% food/ 350 cc's fluid. On [DATE] Breakfast, nothing marked; dinner, nothing marked; and supper, bites food/450 cc's fluid. On [DATE] Breakfast, 0 food/240 cc's fluid; dinner, nothing marked; and supper, nothing marked. On [DATE] Breakfast, bites food/sips fluid; dinner, bites food/sips fluid; and supper, 100% food/360 cc's fluid. On [DATE] Breakfast, nothing marked; dinner, 0 food/ 0 fluid. The Nutrition Risk assessment dated [DATE] documented Resident #4's food intake met less than 25% of his/her estimated needs, and consumed less than 1000 cc's of fluids a day. The assessment identified Resident #4 needed an estimated 1800 cc's of fluid a day. The Dietary Progress Notes dated [DATE] documented Resident #4's meal intakes marginal since admission, would need to encourage intakes. On [DATE] the notes documented Resident #4's intakes at 0 to 25% and 600 cc's fluids a day. They needed to encourage intakes to meet Resident #4's needs. Nurse ' s notes dated [DATE] at 11:05 a.m. identified Resident #4 died . The death record dated [DATE] documented Resident #4's immediate cause of death [MEDICAL CONDITION]. Interviews: During an interview on [DATE] at 8:28 a.m. the PACE Advanced Registered Nurse Practitioner (ARNP) stated she visited Resident #4 with a nurse on [DATE]. Resident #4 was semi conscious and responded to pain. The ARNP stated Resident #4 should have been taken off medications sooner due to the degree of sedation. The ARNP stated Resident #4's poor oral intake could have contributed to his/her declining condition and subsequent death. The clinical record lacked any documentation by the ARNP. During an interview on [DATE] at 9:27 a.m. the Physician's Office Nurse stated they received a report of Resident #4 being lethargic and eating poorly on [DATE]. The nurse stated they received no other reports regarding level of consciousness and poor oral intake. On [DATE] the facility reported Resident #4 unresponsive. During an interview on [DATE] at 2:26 p.m. the Physician stated if the facility had reported Resident #4 did not consume adequate food and fluids due to sedation she would have referred them to Psychiatry for medication changes. The Physician stated Resident #4 was sedated in the hospital, but staff assisted him/her with oral intake and he/she did okay. The Physician could not say for sure if the sedation and poor oral intake contributed to Resident #4's decline and subsequent death. During an interview on [DATE] at 12:07 p.m. the Psychiatric practitioner stated he certainly would have made changes to Resident #4's psychiatric medications if he had known his/her condition sooner. During an interview on [DATE] at 4:05 p.m. Staff A, Director of Nursing (DON) stated Resident #4 did okay, she responded but he/she kept going down. When asked about all the documentation in Resident #4's chart about being lethargic and unresponsive at times since his/her admission, the DON stated PACE saw Resident #4 regularly. During an interview on [DATE] at 8:33 a.m. Staff H, Social Worker, stated they were all concerned about Resident #4's condition. Staff H stated Resident #4 came in to the facility lethargic. Staff H stated Resident #4 opened his/her eyes momentarily the day he/she came, otherwise he/she never opened them for her. Staff H stated she could never engage Resident #4 due to the lethargy. Staff H stated Resident #4 was on so many psychoactive medications at high doses. Staff H talked to the PACE social worker, and thought they were going to work on reducing the medications. Staff H stated Resident #4 was not able to do the paper work when he/she came in to the facility due to the lethargy. During an interview on [DATE] at 10:04 a.m. Staff D, Certified Nursing Assistant (CNA) stated Resident #4 was not good. Staff D stated Resident #4 did not really talk. Staff D stated she gave Resident #4 a 1 and ,[DATE] bath with Staff B and Resident #4 never woke up. Staff D stated she tried to feed Resident #4 but he/she would not eat. Staff D stated it took 40 minutes to get down 120 cc's (4 ounces) of liquid. During an interview on [DATE] at 10:08 a.m. Staff E, CNA stated Resident #4 would yell "Help". Staff E stated she sat with Resident #4 and tried to feed him/her. Resident #4 would let food sit in his/her mouth and sip liquids. Staff E stated she hardly ever saw Resident #4 with his/her eyes open. Resident #4 would call "Momma, Momma". Staff E stated when they put Resident #4 in the recliner he/she didn't wake up. Staff E stated she would only leave Resident #4 there a short time, they were afraid he/she would fall out. Staff E stated after meals she would put a glove on and make sure there was nothing in Resident #4's mouth, so he/she wouldn't choke. During an interview on [DATE] at 10:14 a.m. Staff F, Physical Therapist stated Resident #4 was rarely alert. Staff F stated if Resident #4 was awake, he/she did not respond appropriately. Staff F stated when Resident #4 did have his/her eyes open they did not focus. Staff F stated they discontinued physical therapy basically due to Resident #4's level of consciousness and inability to progress. Staff F stated they were not able to do much more than range of motion, and restorative could do that. During an interview on [DATE] at 10:18 a.m. Staff G, Licensed Practical Nurse (LPN) stated she called the physician on [DATE]. Staff G stated she had not worked with Resident #4 before and was concerned due to the lethargy and not eating well. It concerned her to give insulin under the circumstances. Staff G stated the Physician stated the lethargy was from the psych medications and she would not address it, so Staff G called PACE. The facility's medication reference, the 2011 Lippincott's Nursing Drug Guide, listed the adverse effects of the following medications: [REDACTED] a. [MEDICATION NAME]: Drowsiness, weakness, tremor and slurring. Increased risk of toxic side effects with [MEDICATION NAME]. Monitor elderly patients for dehydration, sedation and decreased thirst related to CNS effects: can lead to severe dehydration. b. [MEDICATION NAME]: Transient mild drowsiness initially, sedation, depression, lethargy. Increased CNS depression with other sedating medications. c. [MEDICATION NAME]: Dizziness, somnolence, tremor, lethargy. d. [MEDICATION NAME]: Somnolence, drowsiness, and sedation. e. [MEDICATION NAME]: Drowsiness, [MEDICAL CONDITION], weakness, tremor. CNS effects potentiated by use of CNS depressants. f. [MEDICATION NAME]: With serum levels less than 1.5 mEq/L, lethargy, slurred speech, muscle weakness, fine hand tremor. The facility policy for Medication Monitoring regarding Psychoactive drugs indicated residents who received antidepressant, hypnotic, antianxiety, or antipsychotic medications were monitored to evaluate effectiveness of the medication. Every effort was made to ensure that residents receiving the medications obtained the maximum benefits with the minimum untoward effects. For deviations from the recommended dosage and dosage reduction criteria, the clinical record contained evidence to support justification for use of a drug not meeting the dosage criteria but considered clinically appropriate by the physician, including: Documentation that a resident's declin